BREASTFEEDING ON THE WORLDWIDE AGENDA

Transcription

1 BREASTFEEDING ON THE WORLDWIDE AGENDA Fidigs from a ladscape aalysis o political commitmet for programmes to protect, promote ad support breastfeedig

2 Uited Natios Childre s Fud (UNICEF) April 2013 Permissio to reproduce or extract ay part of this documet is required. Requests ca be set to Sada Hlaig, Nutritio Sectio, UNICEF: shlaig@uicef.org Photo credits Cover: UNICEF Idoesia Commuicatio Uit Page 9: UNICEF/NYHQ /Olivier Asseli Page 35: UNICEF Photo Page 38: UNICEF/NYHQ /Roger LeMoye Page 42: UNICEF/Chia/2013/Wu Kaixiag Page 51: UNICEF/NYHQ /Pirozzi Page 63: UNICEF/NYHQ /Aita Khemka.

3 BREASTFEEDING ON THE WORLDWIDE AGENDA Fidigs from a ladscape aalysis o political commitmet for programmes to protect, promote ad support breastfeedig

4 CONTENTS Executive Summary 5 Backgroud 11 Methodology 14 Desk review: evidece, policies ad strategic frameworks for breastfeedig 17 Summary of global evidece o breastfeedig 17 The policy bases for breastfeedig 19 Commitmet to breastfeedig i orgaizatios ad global parterships 20 Global iitiatives, movemets ad parterships 20 uited Natios ad multilateral agecies 22 Doors 24 No-govermetal orgaizatios 26 IYCF policies/strategies i coutries 28 Summary ad aalysis 31 Key fidigs of stakeholder survey 33 Actors 33 Issues 37 Ideas 42 Political Cotexts 49 Discussio 54 The Way Forward 57 Ackowledgemets 62 ANNEX 1 Stakeholders cosulted 64 ANNEX 2 Questioaire 67 ANNEX 3 Stakeholder proposals for stregtheig the breastfeedig ivestmet case 70 ANNEX 4 Origial framework Professor Jeremy Shiffma 72 Acroyms 73 Refereces 74

5 BREASTFEEDING ON THE WORLDWIDE AGENDA Executive Summary Itroductio Breastfeedig is oe of the best values amog ivestmets i child survival, recogized for both the magitude of its effect o mortality ad the effectiveess of itervetios to promote it 1. There is compellig scietific evidece 2 that optimal breastfeedig of ifats uder oe year could prevet aroud a millio deaths of childre uder-five i the developig world. Yet global rates of breastfeedig rates have remaied stagat sice 1990 with oly 36 per cet of childre less tha six moths exclusively breastfed i Why has such strog scietific evidece ot bee traslated ito political ad door commitmet for breastfeedig at the global level ad i high burde coutries? What ca the global breastfeedig policy commuity do to augmet attetio ad commitmet to breastfeedig? Seekig aswers to these questios, UNICEF s Nutritio Sectio coducted a ladscape aalysis to assess the political commitmet ad priority for breastfeedig itervetios globally ad i selected coutries, i order to determie the eed for, ad potetial beefits of, a targeted iitiative to ehace leadership ad advocacy. Political commitmet is defied here as the degree to which leaders of iteratioal orgaizatios ad atioal political systems actively pay attetio to a issue ad provide resources commesurate with the issue s importace 4. This aalysis has focused primarily o the former. It is framed with the ackowledgemet that a large variety of determiats ifluece coutry ad thereby global breastfeedig patters, ad focus the fidigs ad coclusios o the cotributio a global commuity of advocates might make to improvig breastfeedig amidst this causal complexity, ad particularly i ifluecig oe aspect of the causal picture: global political attetio ad leadership. The aalysis does ot address issues ad solutios which are outside of this remit, for example those relatig to legislatio, programmatic strategies, commuicatio for behavior chage ad so o. UNICEF 5

6 A eviromet that is policy-rich ad implemetatio-poor The methodology for the ladscape aalysis ivolved a desk review ad a stakeholder survey, ad the way forward was iformed by the outcomes of a stakeholder cosultatio to review the fidigs of the ladscape sca. The desk review assessed the status of breastfeedig withi the publically-available policy/strategy frameworks ad statemets o the websites of selected, relevat global parterships, orgaizatios ad multi-coutry reviews or assessmets ad a stakeholder aalysis ivolvig 44 participats idetified as key actors i the protectio, promotio ad support of breastfeedig practices, workig at the global, regioal ad coutry level for a rage of differet orgaizatios. It explored their views regardig the curret state of political priority for breastfeedig programmes; perceived barriers ad opportuities, ad suggestios for the way forward. The stakeholder survey results are heavily idebted to a framework developed by Professor Jeremy Shiffma to study issue attetio for global health iitiatives, drawig o it to examie political priority for breastfeedig. Shiffma s framework defies four mai categories ifluecig issue attetio for global health: actor power, issue characteristics, ideas ad political cotexts. These categories are useful because they reveal uderlyig factors eablig or hiderig priority for breastfeedig programmes. I particular, they help us uderstad the dyamics at play withi the breastfeedig policy commuity ad broader developmet cotext, ad their resultig impact o prioritizatio of breastfeedig. Key Fidigs Three mai issues that eed to be addressed have emerged from this ladscape aalysis: 1. Polarizatio ad lack of a uified voice 2. Leadership gap 3. Need to recast the arrative Despite the compellig evidece ad the presece of ample policy ad strategy frameworks, as well as experieces of sigificat success i some coutries to icrease breastfeedig rates, breastfeedig advocates have struggled at the global level to defie a commo policy ageda ad to garer attetio ad commitmet. Growig polarizatio, played out very publically, over private sector egagemet ad their role i ifat ad youg child feedig, is impactig progress ad support. A sigificat gap i leadership ad iadequate guidig istitutios over the past two decades has also impacted attetio ad commitmet to breastfeedig. Stakeholders are hopeful a policy widow ow exists to recast the arrative o ifat ad youg child feedig. They are ethusiastic ad optimistic about the potetial of bold, iovative ad fresh advocacy ad commuicatio, deployed both horizotally ad vertically, to advace their cause. The desk review foud that all of the utritio global iitiatives/ parterships do reflect breastfeedig quite strogly i their strategies ad other documets, but the child survival iitiatives appear to provide a more toke metio of breastfeedig. A geeral observatio is that for most orgaizatios breastfeedig features more strogly i policy ad strategy frameworks tha i actual programmes ad implemetatio at scale, with o systems ad accoutability to report o coverage of itervetios. This is also true for may coutries, as per several IYCF policy ad programme assessmets coducted i recet years, poitig to a overall eviromet that may be characterized as relatively policy-rich ad geerally implemetatio-poor. Exclusive breastfeedig as a goal, programme compoet or outcome idicator is the breastfeedig practice that teds to be most commoly reflected across the parterships, differet types of agecies ad coutry frameworks, although a sigificat proportio also refer to early iitiatio ad cotiued breastfeedig or just optimal breastfeedig practices. It is importat that specific ad clear referece is made across all partership, orgaizatio ad coutry frameworks to all recommeded breastfeedig practices, as each plays a importat role i child survival, growth ad developmet. The sole focus o exclusive breastfeedig may also cotribute to the breastmilk substitute idustry s curret strategies to segmet the market ad promote follow-o formula ad growig-up milks i violatio of the Iteratioal Code for Marketig of Breastmilk Substitutes (Code) capitalizig o ad actually ecouragig a mistake belief that breastfeedig exclusively i the first six moths is the oly priority, ad ot cotiued breastfeedig, which is igored. A predomiace of promotio of breastfeedig is refereced i may of the strategy frameworks ad statemets. The term promotio is ofte iteded to imply the full set of actios to 6 BREASTFEEDING ON THE WORLDWIDE AGENDA

7 improve breastfeedig, which eed to also iclude professioal support by skilled health providers, lactatio couselors ad commuity workers ad legislative ad policy measures to protect breastfeedig, icludig the Code for subsequet World Health Assembly (WHA) resolutios, materity protectio ad workplace policies. Therefore as such the term promotio is a misomer for a all-ecompassig approach to improvig breastfeedig, as promotio is about messagig ad iformatio dissemiatio. This may be due to the domiat otio that improvig breastfeedig is primarily behavioural as well as a lack of uderstadig of the role of professioal ad lay support ad the importace of protectig breastfeedig. O the other had, a more comprehesive reflectio of approaches to improvig breastfeedig was observed across a rage of orgaizatios. The key fidigs of the stakeholder survey, usig Shiffma s framework, iclude the followig: I terms of the ACTORS ivolved i breastfeedig, the stakeholders highlight that the icrease i visibility ad actio for child uderutritio ad stutig has ot bee accompaied by icreased visibility for breastfeedig. Most stakeholders raked political priority for breastfeedig as average to low, despite it beig a essetial pillar of ifat ad youg child feedig programmes. A major fidig of the survey was that advocates for breastfeedig lack a commo ageda with a shared visio of chage, costraiig their ability to ifluece policy makers ad raise resources. Several stakeholders characterized breastfeedig as a orpha issue ot grouded i a cohesive advocacy commuity. Civil society ad NGO stakeholders are polarized i particular over whether ad how to egage with the food idustry to improve ifat ad youg child feedig practices. These disagreemets are played out i the media, i reports questioig the motives of orgaizatios ad press releases ad at iteratioal orgaizatios, ad at iteratioal meetigs. This public divisiveess further harms efforts to advace a coheret breastfeedig/iycf ageda. Respodets also emphasized siloig of health ad utritio programmes i UN orgaizatios, door govermets ad developig coutries is a costrait, alog with fragmetatio i the utritio commuity. Global leadership ad champios are critical for advocacy success. Stakeholders voiced a commo call for leadership, both idividual ad orgaizatioal, callig this the sigle most importat igrediet for successful advocacy. Some respodets commeded the curret UNICEF Executive Director Athoy Lake s leadership to raise global awareess about stutig. However most iterviewees gave WHO ad UNICEF barely passig marks for political leadership o breastfeedig i recet years, sayig it has falle off the map. Respodets testified limited fudig was severely restrictig their ability to advocate for breastfeedig globally ad at the regioal ad coutry level. With respect to the mai ISSUES aroud breastfeedig programmig, the stakeholders poited a urget eed to recast breastfeedig advocacy ad commuicatio for a 21st cetury world, takig ito accout factors such as globalizig markets, rapid urbaizatio ad icreases i workig ad migrat mothers ad ew commuicatio techologies. The task at had is how to deploy the compellig evidece ad reframe it i a bold ad iovative way that appeals to all the differet costituecies for advocacy, particularly political leaders ad policymakers who eed to be brought o board. A sigificat scalig up of cotiuous advocacy, commuicatio ad social mobilizatio is eeded to icrease attetio, commitmet ad ivestmet i actios to overcome barriers to optimum breastfeedig i the developig world, said respodets to the ladscape aalysis. A secod breastfeedig revolutio to recast breastfeedig for today s world must be created: more of the same will ot produce results. Stakeholders call for effective leadership ad guidig istitutios to address the scale of the issue. The eed to protect breastfeedig is becomig more urget as formula compaies ifluece grows i emergig ecoomies. While stakeholders debate private sector egagemet, baby food compaies are poised to grow by 37 per cet betwee 2008 ad 2013 i. Almost two-thirds of this growth will come from Asia Pacific. To achieve it, compaies will eed to persuade mothers to give up breastfeedig 5. Respodets sigaled strog cocer over the growig success of formula compaies i positioig artificial feedig as the desirable, moder choice of families i emergig ecoomies. They reaffirmed the eed for a revitalized strategy to protect breastfeedig rights. i Ifat formula sales are projected to grow from US$11.5 $42.7 billio betwee 2008 ad 2013, accordig to Euromoitor Iteratioal, a idustry group. UNICEF 7

8 Stakeholders also coveyed a sese of ucertaity surroudig the best approaches to address sub-optimal breastfeedig practices ad barriers wome face. They called for more ivestmet i research to better uderstad the dyamics ihibitig or eablig broader adoptio of exclusive breastfeedig by families ad commuities ad i improved approaches to protect, promote ad support breastfeedig. This is despite the fact that a set of evidece-based itervetios does exist; the ucertaity may be related to isufficiet dissemiatio ad iadequate moitorig of their status, perhaps cotributig to the otio we do t kow how to improve breastfeedig practices. Regardig the mai IDEAS suggested for movig forwards, it is emphasized that the utritio commuity has made huge progress of late to alig behid a package of cost-effective itervetios to reduce child uderutritio. Stakeholders must ow reach a techical ad policy cosesus o scalig up breastfeedig programmes as the foudatio of a shared advocacy ageda. While the ratioale for ivestig i breastfeedig as a best buy i global health is o loger i doubt ad there is broad agreemet o what eeds to be doe stakeholders must work towards cosesus o how to do it. The mai issues requirig further cosultatio are agreemet o the role of the private sector i improvig Ifat ad Youg Child Feedig (IYCF) practices, stregtheig the ivestmet case for scalig up programmes, ad measuremet of itervetios. Stakeholders also said more ad better evidece is eeded to demostrate that scalig up IYCF programmes will pay sigificat divideds to icrease atioal productivity ad develop huma capital. They placed a high priority o stregtheig the ivestmet case for the 1,000 days to commuicate its ecoomic beefits to govermet leaders. The stakeholders recommeded a diagoal advocacy approach. This implies either a solely horizotal approach of itegratig ad maistreamig advocacy for breastfeedig withi existig iitiatives, or a solely vertical approach focusig o breastfeedig separately. It implies both itegratio ad ifluecig withi existig parterships ad etworks, especially the Scalig Up Nutritio (SUN) movemet ad the child survival iitiative A Promise Reewed (APR), ad at the same time some specific vertical advocacy o breastfeedig. This will require a strategic, creative, iovative ad forwardlookig craftig of the advocacy approach to geerate attetio ad excitemet it ca be doe. Aalysis of the POLITICAL CONTEXT highlights the rise of utritio o the global developmet ageda as a ecouragig tred. Stakeholders are hearteed the 1,000 days widow of opportuity advocacy message ii is resoatig with political leaders, ad ackowledge the potetial of the Scalig Up Nutritio Movemet (SUN) to spur coutry actio. Stakeholders geerally voiced ethusiasm for the potetial to advace this via the SUN movemet. It provides a opportuity to reverse the tred of low visibility ad commitmet for breastfeedig. Furthermore, breastfeedig sits at the exus of SUN ad APR, as well as other child health iitiatives. These are uprecedeted opportuities to repositio breastfeedig for the 21st cetury, which have ot bee yet bee capitalized o. The breastfeedig advocacy costituecy must broade ad deepe its reach if it is to raise attetio ad icrease political commitmet. The timig is right to seize the opportuity ad brig a issue log eglected back to ceter stage with the right combiatio of leadership, timig, resources ad civil society mobilizatio. However, several civil society represetatives cautioed a coflict of iterest policy is urgetly eeded to clarify the role of the private sector i iitiatives ivolvig public-private utritio parterships such as the SUN ad 1000 Days. The stakeholders called for a social movemet for breastfeedig that taps ito families aspiratios ad uses the potetial of ew commuicatio techologies. Respodets also recommeded the IYCF commuity make commo cause with other advocacy costituecies, give the scale of the utritio challege, ad its multi-sectoral ature. Recommedatios These proposals build o key fidigs of the desk review ad stakeholder feedback, ad draw upo the outcomes of a small stakeholder cosultatio i February They are discussed i more detail i Part 2, The Way Forward. ii 1,000 Days, 8 BREASTFEEDING ON THE WORLDWIDE AGENDA

9 1. Recast the arrative: defie a shared advocacy ad commuicatio visio ad ageda for breastfeedig ad complemetary feedig, with emphasis o recastig the arrative for the 21st cetury; develop associated advocacy materials, strategies ad tools. Overcome the issue fatigue o breastfeedig ad re-eergize the debate. This should lead to a trasformatio of how the issue is perceived ad addressed, coveyig that it is doable ad importat to improve IYCF practices. The arrative must strogly reflect a positive voice, rather tha the egative attetio the issue curretly receives. Stregthe the ivestmet case for breastfeedig, buildig o research highlightig its beefits, cost savigs for govermets, ad costs of deliverig a package of effective itervetios. Itegrate these fidigs ito existig ivestmet cases for utritio ad materal, ewbor ad child health. Best practices i couselig ad commuity mobilizatio eed to be urgetly applied ad programmes scaled up. Here a commuity outreach worker teaches a woma proper breastfeedig techiques i Burkia Faso s Plateau- Cetral Regio. UNICEF 9

10 2. Advocate ad ifluece: Itegrate this shared IYCF ageda ito existig global advocacy iitiatives for utritio ad materal, ewbor ad child health otably Scalig Up Nutritio ad A Promise Reewed. Develop ad execute coordiated commuicatio plas to support high-level advocacy for the 1,000 days widow of opportuity ad breastfeedig. Build likages with related advocacy commuities. Deploy the advocacy strategies ad messages i appropriate global fora, at high level i coutries ad through relevat chaels to the public. Ivolve global ad atioal champios to promote the message, both celebrities ad high-level persoalities. 3. Esure a uified voice: Focus o buildig cosesus goals ad strategies ad a uified voice which all actors ca rally aroud. Create a space for policy dialogue where outstadig issues of disagreemet ca be debated. Support civil society orgaizatios ad NGOs to urture a social movemet repositioig breastfeedig as the optimum feedig choice for the moder woma ad child. 4. Provide strog leadership for cohesive actio ad results: Provide leadership ad backboe support to guide a uified advocacy leadership iitiative. Explore the possibilities to shape a global coalitio to advace the ageda. 5. Mobilize resources, actio ad accoutability: promote accelerated actio ad mobilize resources ad commitmet towards achievemet of full coverage of the IYCF idicators ad moitor progress of the actios towards these results. Develop ad promote a global stadard scorecard for performace o the IYCF practice idicators as well as key aspects of policy, programmes ad itervetio coverage. Icrease resourcig for IYCF ad breastfeedig. Trasform the toke attetio breastfeedig ofte receives ito a oegotiable commitmet to deliver a comprehesive package of health ad utritio itervetios at scale. 10 BREASTFEEDING ON THE WORLDWIDE AGENDA

11 BACKGROUND I the secod decade of the 21st cetury, uderutritio still causes 45% of all child deaths iii, ad some 165 millio childre aroud the world are stuted iv. Amog the mai causes of stutig is chroic deficiecy i utritio durig the first 1,000 days of a child s life, from coceptio to age two 6 the timeframe whe optimal ifat ad youg child feedig is so crucial. Frequet ifectious illess durig this period also plays a major role ad lack of breastfeedig substatially elevates the risk of illess. The damage stutig causes is irreversible. Breastfeedig is a key strategy to reduce child uderutritio ad reach Milleium Developmet Goal (MDG) Four: Reduce by two-thirds, betwee 1990 ad 2015, the uder-five mortality rate. It is also idispesable to reachig MDG Oe: Halve the proportio of people who suffer from huger. The evidece for its wide-ragig beefits is compellig, ad a evidece-based package of effective itervetios to improve breastfeedig practices is available. FIGURE 1 Sice 1990, there has bee egligible progress to raise the global rate of exclusive breastfeedig Exclusive breastfeedig rates amog childre less tha 6 moths sice 1990 plotted agaist timelie of key evets to promote breastfeedig durig the same time period 100% % Ioceti Declaratio Baby-Friedly Hospital Iitiative World Breastfeedig Week first celebrated UN Milleium Developmet Goals ILO Materity Protectio Covetio Global Strategy for Ifat & Youg Child Feedig Expaded Ioceti Declaratio Lacet Uderutritio Series World Health Assembly resolutio Lauch of SUN & 1,000 Days Iitiative G8 commitmet to reduce uderutritio p p p p p p p p p 0% Note: The red lie shows the rate of exclusive breastfeedig, which has icreased from 32 to 40 percet betwee 1995 ad 2011, based o available tred data from a subset of 77 coutries. Comparable global data is ot available for each of the years plotted i the chart, or for the baselie year of Source: UNICEF iii iv The Lacet s 2013 Series o Materal ad Child Uderutritio Executive Summary Stutig, or chroic uderutritio, meas a child is too short for their age compared to the media WHO growth stadards UNICEF 11

12 Global actio to promote breastfeedig practices spas more tha three decades durig which developmet parters have developed policy, strategy ad programme frameworks, compiled the evidece o the wide rage of beefits of breastfeedig, worked to raise breastfeedig rates i developig atios through support to implemetatio of a rage of itervetios to protect, promote ad support breastfeedig, ad reflected breastfeedig i global parterships ad movemets. The graphic below shows a timelie of some of these key global efforts sice the early 1990s alogside the global rate of exclusive breastfeedig: Despite these efforts, the data cofirms a harsh fidig: sice 1990, there has bee egligible progress to raise the global rate of exclusive breastfeedig uder six moths, which remais uder 40 per cet. Some coutries have demostrated it is possible to make dramatic progress 7. But of the 11 highly populated coutries which cotai a estimated two-thirds of the o-exclusively breastfed childre i the developig world, all but three have either egative treds or o progress betwee The lack of progress i most of these coutries sigificatly impacts the global rate of exclusive breastfeedig. I developig coutries, of approximately 56 millio ifats less tha six moths of age, approximately 22 millio are exclusively breastfed, while over 34 millio childre are ot. Eighty per cet FIGURE 2 Treds i exclusive breastfeedig rates amog childre <6mo i the coutries represetig two thirds of the burde of o-exclusively breastfed childre Idia (98; 06) Chia (08) Nigeria (99; 08) Idoesia (97; 07) Philippies (97; 08) Ethiopia (00; 10) Vietam (97; 06) Pakista (95; 07) Bagladesh (97; 11) DR Cogo (95; 10) Excludig Chia for which o tred data is available Source: UNICEF database for The State of the World s Childre BREASTFEEDING ON THE WORLDWIDE AGENDA

13 FIGURE 3 Te large coutries have aroud two-thirds (or over 21 millio) of the 34 millio o-exclusively breastfed childre i all developig coutries Bagladesh Ethiopia Vietam Philippies DR Cogo Pakista Idoesia Nigeria Chia Idia 0 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 7,000,000 8,000,000 Estimated, approximate umbers of o-exclusively breastfed childre Data sources: most recet exclusive breastfeedig data poit from UNICEF database ad populatio figures i The State of the World s Childre 2012 of these childre who do ot beefit from exclusive breastfeedig i developig coutries live oly i 29 coutries. From these 29 coutries, the 10 large coutries above have two-thirds (over 21 millio) of the approximate umbers of o-exclusively breastfed childre i developig coutries (Figure 3). There seems to be a relatively limited focus o breastfeedig, accordig to a 2011 aalysis of political, fiacial ad other commitmets to advace the UN Global Strategy o Wome ad Childre s Health 8. May coutry-based stakeholders cofirmed the low levels of commitmet for breastfeedig i their settig, ad the challeges this poses to programmig. Others saw advocacy gais: There s bee a huge amout of progress made to alig the utritio commuity, said oe respodet. But she added: I have t see breastfeedig s potetial role i that traslate ito much actio. Why has such strog scietific evidece ot traslated ito political ad door commitmet for breastfeedig at the global level ad i high burde coutries? What ca the global breastfeedig policy commuity do to augmet attetio ad commitmet to breastfeedig? Seekig aswers to these questios, UNICEF s Nutritio Sectio coducted a ladscape aalysis to assess the political commitmet ad priority for breastfeedig itervetios globally ad i selected coutries, i order to determie the eed for, ad potetial beefits of, a targeted iitiative to ehace leadership ad advocacy. UNICEF 13

14 METHODOLOGY This ladscape aalysis cosists of two major compoets a desk review summarizig the status of evidece ad policy/strategic frameworks; ad a stakeholder survey of perceptios ad recommedatios. The way forward is iformed by the outcomes of a small stakeholder cosultatio coducted i February 2013 i which the fidigs ad recommedatios of the ladscape aalysis were reviewed ad articulatio of key issues ad elemets for the future directio was refied. The desk review ivolved a olie search of the websites of the seve global parterships, five UN/multilateral agecies, four doors ad six o-govermetal orgaizatios to idetify documets ad statemets available i the public domai. It assessed how breastfeedig is reflected withi the strategies, advocacy publicatios ad other guidig documets ad statemets of major global movemets ad parterships comprisig multiple types of agecies ad those of selected orgaizatios, as well as policies ad strategies i coutries. The latter iformatio was obtaied from a selectio of multi coutry assessmets ad review reports. The desk review is ot iteded to be a comprehesive or detailed assessmet of the frameworks of all coutries or of every orgaizatio ad partership which supports utritio or child survival, or the details or status of programmes. The fidigs are based o iformatio publically available, which may ot reflect the full ad up to date picture of the policies or programmes of a partership or orgaizatios, ad the coclusios are by ature qualitative. The survey of stakeholder views is based o resposes to a structured questioaire ad related grey literature search. The questioaire was circulated to stakeholders idetified as key actors i the protectio, promotio ad support of breastfeedig practices, workig at the global, regioal ad coutry level. It explored their views regardig the curret state of political priority for breastfeedig programmes; perceived barriers ad opportuities, ad suggestios for the way forward. Forty-four resposes were received from UNICEF, WHO & PAHO, the World Bak, door agecies, academics, NGOs, civil society orgaizatios ad cosultats. (See Aex 1) Twety-six hour-log Skype calls were coducted, ad 18 writte questioaires were received. Geographic distributio icluded North America, Europe, Asia, Africa ad the Middle East. Resposes were evely matched betwee exteral stakeholders ad UNICEF staff. To preserve cofidetiality, the letter S is used to idetify stakeholder quotes, ad Q, resposes received by questioaire. For purposes of aalysis, this study uses a framework developed by Jeremy Shiffma, a political scietist ad professor at America Uiversity. Shiffma has pioeered a ew field of iquiry to uderstad why some global health iitiatives have geerated political commitmet ad fudig while others are eglected, whe severity of disease burde is ot the decidig factor 4. Shiffma s framework defies four mai categories ifluecig issue attetio for global health: actor power, issue characteristics, ideas ad political cotexts. These categories are useful 14 BREASTFEEDING ON THE WORLDWIDE AGENDA

15 TABLE 1 A framework for aalyzig issue attetio i global health ad utritio Category Factor Explaatio Why It Matters Actors Policy commuity Brigs etworks together; coects Ehaces authority cohesio differet types of orgaizatios Leadership Strog champios for the cause to defed the issue, ispire actio ad brig policy commuities together Defie the issues, ispire actio, brig policy commuities together Guidig istitutios Coordiatig mechaisms Sustaiability Civil Society Egaged social istitutios that press Source of exteral pressure Mobilizatio political authorities to act Doors v Fudig orgaizatios providig Resources ad policy voice support for programmes ad advocacy Issues Importace Importace of issue relative to other issues; credible idicators the are key Prefereces for causes perceived to be serious; idicators alarm politicias Tractability Extet to which the problem is (perceived to be) surmoutable; clear cost effective itervetios are key Policymakers are more likely to act o issues they thik they ca do somethig about Cotetiousess Extet to which addressig the issue icites oppositio Ihibits progress; ispires actio Allure Attractiveess of the issue to those who Reputatioal effects might wat to address it Ideas Iteral Frame Commo policy commuity uderstadig Avert fractiousess, of problems ad solutios ehace credibility Exteral Frame Public positioig of the issue that Oly some resoate widely; ispires exteral audieces to act differet frames resoate with differet audieces Political Cotext Policy Widows Momet i time whe coditios alig favorably for a issue Preset widows of opportuity Existig Health Priorities Priority for other health issues May facilitate or divert policymaker attetio Adapted from Jeremy Shiffma s Framework of Determiats of Global ad Natioal Attetio for Health Issues i Low-icome Coutries vi v Added to Shiffma s framework for the purpose of this aalysis vi See Aex 3 for a summary of Shiffma s origial framework UNICEF 15

16 because they reveal uderlyig factors eablig or hiderig priority for breastfeedig programmes. I particular, they help us uderstad the dyamics at play withi the breastfeedig policy commuity ad broader developmet cotext, ad their resultig impact o prioritizatio of breastfeedig. This framework was also used for case studies o materal mortality 4 ad ewbor survival 9, which ca provide valuable lessos for breastfeedig stakeholders. While UNICEF s questioaire ad Shiffma s framework both focus o high-level advocacy, it is ackowledged that there are may other determiats of breastfeedig practices, the aalysis of which does ot lie withi the scope of a ladscape aalysis o political commitmet to breastfeedig. To provide perspective o stakeholder iputs, a PubMed search was coducted usig key words related to the ladscape aalysis. It yielded very few articles. A grey literature search was more productive. Some of those fidigs are cited i the sectio o the stakeholder survey fidigs. The limitatios of the methodology of the stakeholder survey iclude factors idetified by Shiffma ad co-author Stephaie Smith i their materal mortality case study: the difficulty i cotrollig for cofoudig variables of ifluece, ad i assessmet of the relative weight of factors 4. As they further ote, the study of issue ascedace ad eglect i global health is i its ifacy ad requires substatially more research. A survey of perceptios ad views is by ature subjective ad qualitative. 16 BREASTFEEDING ON THE WORLDWIDE AGENDA

17 DESK REVIEW: EVIDENCE, POLICIES AND STRATEGIC FRAMEWORKS FOR BREASTFEEDING Summary of global evidece o breastfeedig The evidece o the may ad remarkable beefits of breastfeedig is well kow. High coverage with optimal breastfeedig practices has potetially the sigle largest impact o child survival of all prevetive itervetios. The 2003 Lacet Child Survival Series 10 raked breastfeedig (exclusive for the first six moths ad cotiued breastfeedig from 6 11 moths) as the umber oe prevetive itervetio, potetially reducig uder-five child deaths by 13%, while complemetary feedig cotributes a further 6%. FIGURE 4 Breastfeedig has the sigle largest potetial impact o child mortality of all prevetive itervetios Excl breastfeedig for 6m + cotiued BF to 12m 13% Isecticide treated materials 7% Complemetary feedig 6% Zic 5% Hib vaccie Clea delivery 4% 4% Water, saitatio, hygiee Ateatal steroids 3% 3% 0% 2% 4% 6% 8% 10% 12% 14% Source: Lacet Child Survival Series The latest aalysis of the evidece, published i the 2013 Lacet Series o diarrhea ad peumoia 11, models the large impact of breastfeedig o mortality due to the two major childhood killers, potetially avertig over 250,000 deaths. Further, the 2013 Lacet Nutritio Series 12 states that sub-optimum breastfeedig amog childre uder two years results i more tha 800,000 child deaths aually, or 11.6% of all deaths. There is also growig evidece of the sigificat impact of early iitiatio of breastfeedig o reducig overall eoatal mortality: recet studies UNICEF 17

18 studies from Ghaa ad Nepal show early iitiatio withi the first hour could prevet aroud 20% of eoatal deaths FIGURE 5 The risk of mortality for o-breastfed childre is vastly elevated compared to exclusively breastfed childre i the first 6 moths of life Diarrhoea mortality Peumoia mortality All cause mortality Exclusive breastfeedig Not breastfeedig Source: Lacet Nutritio Series 2008 from Ghaa ad Nepal show that early iitiatio withi the first hour could prevet aroud 20% of eoatal deaths 13, 14. This becomes icreasigly importat as patters of the causes of child deaths shift towards a larger proportio of deaths due to eoatal factors. A large body of evidece is also available o the beefits of breastfeedig for child utritio status 15, 16 its protective effects for later obesity ad various chroic, o-commuicable diseases 17, its impact o itellectual ad motor developmet ad short ad log term beefits for materal health 18. Ecoomic beefits are also sigificat i terms of reduced health care costs 19, 20, fewer abseces of caregivers from work due to child illess 21, ad a reduced drai o household resources for breastmilk substitutes ad other supplies 22. Although the ecoomic costs of ot breastfeedig geerally are cosidered to be greatest for poor households ad poor coutries, the evidece suggests that the impact i developed coutries is also serious 23. Scietific evidece has bee gathered o the effectiveess of a umber of itervetios to improve breastfeedig practices. These iclude materity care practices, where istitutioal chages are demostrated to effectively icrease breastfeedig iitiatio ad duratio rates 24, 25, 26. Professioal support by health providers has prove effective i extedig the duratio of ay breastfeedig 27. Lay couselors have bee show to be most effective i icreasig the iitiatio ad duratio of exclusive breastfeedig 28. Further, various types of commuitybased breastfeedig promotio ad support ca improve breastfeedig practices i developig coutries 29. I terms of commuicatio, media campaigs improve attitudes towards breastfeedig ad icrease iitiatio rates 30 ad social marketig has bee established as a effective behavioural chage model for a wide variety of public health issues, icludig breastfeedig 31. Evidece from idustrialized coutries has show how workplace support programmes icrease the duratio of breastfeedig 32, ad a study examiig the relatioship 18 BREASTFEEDING ON THE WORLDWIDE AGENDA

19 FIGURE 6 Breastfeedig promotio could potetially prevet 250,000 child deaths due to peumoia ad diarrhea Peumococcal vaccie Case maagemet of eoatal ifectios Breastfeedig promotio Case maagemet of peumoia ifectios Improved water source Zic supplemetatio Hib vaccie Hadwashig with soap Improved saitatio ORS Rotavirus vaccie Hygieic disposal of childre s stools Vitami A supplemetatio Zic for treatmet of diarrhea Atibiotics for dysetery 50, , , , , , ,000 Source: Adapted from The Lacet 2013, Childhood Peumoia ad Diarrhea Series, Paper 2. betwee advertisig i a paretig magazie ad breastfeedig foud that whe frequecy of advertisemets for artificial feedig icreased, the percetage chage i breastfeedig rates reported the ext year teded to decrease 33. Aalysis reveals a sigificat correlatio betwee higher exclusive breastfeedig rates ad higher levels of Code implemetatio i 108 coutries for which UNICEF has data o both variables. The policy bases for breastfeedig The right to utritio is protected by iteratioal huma rights law, icludig the Covetio o the Rights of the Child, which commit ratifyig coutries to promote ad protect the utritioal wellbeig of wome ad childre, ad report o their progress towards this goal 34. Global policy frameworks which address breastfeedig iclude: UNICEF 19

20 The 1981 Iteratioal Code of Marketig of Breastmilk Substitutes is oe of the first global policy istrumets for the protectio of breastfeedig, ad is further articulated ad updated by a series of subsequet relevat WHA resolutios. I 2012, the World Health Assembly edorsed the six global targets for utritio, oe of which is exclusive breastfeedig, as well as the implemetatio pla for materal, ifat ad child utritio. A umber of other WHA resolutios also refer to breastfeedig Ioceti Declaratio o the Protectio, Promotio ad Support of Breastfeedig 35. The 1990 Declaratio sets out four targets for atioal actio related to atioal coordiatio, the BFHI, the Code ad materity protectio Covetio o the Rights of the Child 36 (Article 24) which states that govermets must combat disease ad malutritio, through, iter alia, the provisio of adequate utritious foods ad esure that all sectors of society are iformed, have access to educatio ad are supported i the use of basic kowledge of child health ad utritio, icludig the advatages of breastfeedig World Fit for Childre 37 which clearly states to reduce child uderutritio amog childre less tha five years of age by at least oe third, with special attetio to childre uder two years of age ad to protect, promote ad support exclusive breastfeedig for six moths ad cotiued breastfeedig with safe, appropriate ad adequate complemetary feedig up to two years of age ad beyod. WHO/UNICEF Global Strategy for Ifat ad Youg Child Feedig (2003), edorsed by UNICEF s Executive Board ad the World Health Assembly Ioceti Declaratio o Ifat ad Youg Child Feedig 38 which celebrates the 15th Aiversary of the 1990 Declaratio 39 commits to urget actios, ad sets cocrete targets. The 2005 Declaratio adds five more operatioal tar gets to provide a broader focus, icludig policy developmet, protectio, promotio ad support i the health ad other sectors ad at multiple levels, complemetary feedig promotio, ifat feedig i exceptioally difficult circumstaces ad atioal legislatio to give effect to the Code. I 2008, revised IYCF practice idicators were published by WHO. Commitmet to breastfeedig i orgaizatios ad global parterships As metioed i the methodology sectio of the documet, the desk review assessed how breastfeedig is reflected withi the publically-available strategies, advocacy publicatios ad other guidig documets ad statemets of major global movemets ad parterships comprisig multiple types of agecies ad those of selected orgaizatios UN ad multilateral agecies, doors, o-govermetal orgaizatios, as well as policies ad strategies i coutries. It is ot iteded to be a comprehesive or detailed assessmet of the frameworks of all coutries or of every orgaizatio ad partership which supports utritio or child survival, or the details or status of programmes, but to provide some examples summarizig the status of breastfeedig withi strategic frameworks available i the public domai. Brief reflectios are provided o the relative importace breastfeedig appears to have withi these frameworks ad poit to ay major gaps, whether the recommeded breastfeedig practices are comprehesively addressed e.g. early iitiatio, exclusive breastfeedig ad cotiued breastfeedig, ad whether the strategic approach is comprehesive coverig major lies of actio recommeded for protectio, promotio ad support as per the Global IYCF Strategy. Global iitiatives, movemets ad parterships The umber of health ad utritio related parterships, alliaces, iitiatives, campaigs ad movemets cotiues to grow, but for the purposes of this review the focus is oly o a selectio of seve parterships which directly relate to child utritio ad survival. The Scalig Up Nutritio (SUN) global movemet, lauched i 2010, ivolves over a hudred parter orgaizatios, ad Govermets from 34 coutries have siged up so far. The SUN website vii refers to four mai utritio-specific itervetios which the SUN movemet looks to implemetig, icludig: vii 20 BREASTFEEDING ON THE WORLDWIDE AGENDA

21 Support for exclusive breastfeedig up to 6 moths of age ad cotiued breastfeedig, together with appropriate ad utritious food, up to two years of age. The Scalig Up Nutritio Movemet Strategy ( ) 40 refers to four major goals for each coutry participatig i the Movemet. The goals address direct ad uderlyig causes of uderutritio ad take together aim to meet the global targets established by the 2012 World Health Assembly. Oe of the four goals is: Icreased adoptio of practices that cotribute to good utritio (such as exclusive breastfeedig i the first six moths of life). The strategy s sectio o measurig impact also refereces this goal o exclusive breastfeedig as oe of the major results. The SUN Revised Roadmap (2012) 41 refereces the World Health Assembly targets for utritio established i The 2011 first iteratio of the Roadmap cotaied 9 utritio idicators to measure progress, icludig exclusive breastfeedig. The 2010 documet Scalig Up Nutritio: A Framework for Actio reflects breastfeedig as oe of the three mai areas of itervetio to promote good utritioal practices. It is oted that breastfeedig features promietly i the various SUN strategic documets. However, i most of the documets referece is oly made to exclusive breastfeedig, ot to cotiued breastfeedig, which is importat for survival ad utritio status ad also loger term impact o later health ad for the mother s health. The 1,000 Days partership viii is a advocacy partership which promotes targeted actio ad ivestmet to improve utritio for mothers ad childre i the 1,000 days betwee a woma s pregacy ad her child s 2d birthday whe better utritio ca have a life-chagig impact o a child s future ad help break the cycle of poverty. It aims to icrease uderstadig about the crisis of uderutritio i early life ad to elevate utritio o the global ageda. A particular focus is facilitatig coectios betwee advocates ad the global public to lear ad follow the progress of the SUN movemet. Its 80+ listed parters are maily NGOs, but also some doors, UN agecies, govermets, foudatios ad the private sector. Amog the three mai solutios its website lists, breastfeedig is reflected as follows: Promotig good utritioal practices, icludig breastfeedig ad appropriate, healthy foods for ifats. The 1000 Days website cotais resources o feedig practices, icludig techical documets, guidelies, tools, advocacy materials, reports, a ewsroom ad blogs, etc from differet orgaizatios. Its ifographic o the coceptual framework for uderutritio emphasizes poor feedig practices uder the category of care (a importat aspect which is rarely reflected i the varyig iteratios of the coceptual framework of differet orgaizatios ad publicatios), ad highlights the fact that early a millio deaths could be preveted per year if childre were exclusively breastfed for the first 6 moths. The large etwork of parters ivolved i the 1000 Days iitiative ad the commuicatio ad advocacy approaches could also be opportuities for advocacy for breastfeedig. REACH ix ( Reewed Effort Agaist Child Huger ad uderutritio, origially called Edig Child Huger ad Uderutritio Iitiative or ECHUI) is a UN iitiative to accelerate the scale up of food ad utritio actios that was established i 2008 ad is joitly supported by FAO, IFAD, UNICEF, WFP ad WHO. REACH operates at coutry level as a facilitatig mechaism i the coordiatio of UN ad other parters support to atioal utritio scale-up plas through a coordiated, solutioorieted approach uder the leadership of atioal govermets. REACH liks materal ad child utritio, food security, health ad care through a utritio-sesitive approach that itegrates the support ad participatio of differet govermet sectors. Its mai role is facilitatig istitutioal capacity buildig, coordiatio, stregtheig policy plaig ad moitorig skills ad prioritizig scarce govermet resources for atioal actio. To date, REACH operates i 12 coutries i Africa ad Asia. REACH promotes 11 itervetios, amog them breastfeedig ad complemetary feedig, ad provides guides o the itervetios, which are techical primers sythesizig why certai itervetios are importat, how they work, how costeffective they are, ad how to implemet them x. Breastfeedig features promietly i some of the coutry plas, for example viii ix x NB at the time of the desk review, these guides could ot be accessed from the website. UNICEF 21

22 i Mauritaia, oe of the first REACH coutries, where rapid progress i exclusive breastfeedig has bee observed. The Ifat feedig i Emergecies (IFE) Core Group xi is a expert advocacy ad resource group focused o the sigle issue of ifat ad youg child feedig i emergecies. It fuctios as a iteragecy collaboratio with full ad associate members. Its members iclude UNHCR, UNICEF, WFP, WHO, ACF, Save the Childre, Care, IBFAN, Terre des Hommes, ad also idividuals. The Emergecy Nutritio Network (ENN) is the coordiatig agecy ad its website is a home for the resources produced by the IFE Core Group. The IFE Core Group goal is to stregthe the protectio, promotio ad support of safe ad appropriate ifat ad youg child feedig i emergecies. The IFE Core Group s materials cosistetly refer to the full set of actios for breastfeedig (protect, promote ad support). The IFE Core Group s work to date has cetred o developmet of policy guidace ad capacity buildig tools, capturig ad learig from what happes i emergecy respose with regard to ifat ad youg child feedig ad promotig policy ad practice chage i the cotext of preparedess ad respose. The IFE Core Group does ot directly implemet programmes as a group. Key resources produced by the IFE Core Group iclude the 2007 Operatioal Guidace o Ifat Feedig i Emergecies 42, a Orietatio Package o IFE, a traiig package o itegratig IYCF ito commuity maagemet of acute malutritio (CMAM), a media guide, model joit statemet, reviews ad various other resources to be foud i its olie library. The Operatioal Guide outlies six mai steps for esurig ifat feedig is adequately addressed i emergecies, icludig protect,promote ad support optimal IYCF with itegrated multisectoral itervetios. A Promise Reewed xii, a global movemet lauched i 2012, is spearheaded by UNICEF i collaboratio with WHO, USAID ad various other govermets ad parters. It focuses o edig prevetable child deaths, ad seeks to advace the Every Woma Every Child global movemet. The goals refer to itesifyig efforts to address the five coditios resposible for almost 60 per cet of child deaths peumoia, diarrhoea, malaria, pre-term birth complicatios ad itrapartum-related complicatios. The sectio i the APR Road Map 43 o scalig up existig solutios does ot metio breastfeedig. It appears briefly i the aex of the Roadmap where presetatios from the lauch of APR iclude early iitiatio ad exclusive ad cotiued breastfeedig i the listig of the package of evidece-based itervetios across the cotiuum of care. Oe other slide otes that importat practices such as exclusive breastfeedig eed more attetio ad highlights success factors i improvig breastfeedig across the domais of protectio, promotio ad support. It was observed that utritio did ot feature promietly i APR, ad while breastfeedig receives relatively little space ad attetio compared to its potetial cotributio i prevetig ad reducig 13% of child deaths. There is likely to be strog potetial to elevate breastfeedig withi APR ad utilize this iitiative to cotribute to ehacig political commitmet for breastfeedig. Every Woma Every Child xiii, a iitiative of the UN Secretary Geeral lauched i 2010, focuses o wome s ad childre s health. The Secretary Geeral s Global Strategy for Wome s ad Childre s Health 44 icludes exclusive breastfeedig i its descriptio of the package of itegrated itervetios ad services. Similar to A Promise Reewed, this iitiative does ot feature utritio or breastfeedig promietly; for example, a high level Every Woma, Every Child evet i 2011 cotaied either speakers or metio of utritio or breastfeedig. The Partership for Materal, Newbor ad Child Health (PMNCH) xiv, hosted by WHO, was lauched i 2005 ad focuses o improvig the health of wome ad childre ad promotig the cotiuum of care. It jois the reproductive, materal, ewbor ad child health commuities ito a alliace of more tha 450 member orgaizatios from aroud the world. Its Strategic Framework lists exclusive breastfeedig as oe of eight tracer idicators of itervetio coverage. While its budgets are fairly small, its advocacy ad etworkig reach has good potetial for chaelig greater attetio to breastfeedig. Uited Natios ad multilateral agecies UNICEF xv, as the UN agecy madated to advace the rights of childre, addresses breastfeedig primarily through its utritio work, ad also makes referece to it i its health work o ewbor care ad child survival. UNICEF joitly with WHO adopted the 2002 Global Strategy o Ifat ad Youg Child Feedig 46 xi xii xiii xiv xv 22 BREASTFEEDING ON THE WORLDWIDE AGENDA