BREASTFEEDING ON THE WORLDWIDE AGENDA

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

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/NYHQ2012-0260/Olivier Asseli Page 35: UNICEF Photo Page 38: UNICEF/NYHQ2010-0745/Roger LeMoye Page 42: UNICEF/Chia/2013/Wu Kaixiag Page 51: UNICEF/NYHQ2010-3063/Pirozzi Page 63: UNICEF/NYHQ2007-1457/Aita Khemka.

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

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

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 2012 3. 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

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

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

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 2013. They are discussed i more detail i Part 2, The Way Forward. ii 1,000 Days, http://www.thousaddays.org/ 8 BREASTFEEDING ON THE WORLDWIDE AGENDA

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

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

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% 90 80 70 60 50 40% 30 20 10 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% 1990 1991 1992 1993 1994 1995 1996 1997 1998 19992000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 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 1990. Source: UNICEF iii iv The Lacet s 2013 Series o Materal ad Child Uderutritio Executive Summary http://www.imagie.i/sem6-exesum.pdf. Stutig, or chroic uderutritio, meas a child is too short for their age compared to the media WHO growth stadards UNICEF 11

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 1995 2011. 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 100 90 80 70 60 50 40 30 20 10 46 46 28 54 52 42 37 34 32 17 17 17 13 16 37 45 64 24 37 0 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 2012 12 BREASTFEEDING ON THE WORLDWIDE AGENDA

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

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

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

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

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 2003. 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

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 20 15.13 14.4 10 10.53 5 0 1 1 1 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

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 50,000 100,000 150,000 200,000 250,000 300,000 350,000 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

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. 1990 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. 1990 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. 2002 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. 2005 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 http://scaliguputritio.org/about 20 BREASTFEEDING ON THE WORLDWIDE AGENDA

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 (2012 2015) 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 2012. 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 http://www.thousaddays.org/ ix http://www.reachpartership.org/ x NB at the time of the desk review, these guides could ot be accessed from the website. UNICEF 21

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 2012 2015 45 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 http://www.eolie.et/ife xii http://www.apromisereewed.org/ xiii http://www.everywomaeverychild.org/ xiv http://www.who.it/pmch/e/ xv http://www.uicef.org 22 BREASTFEEDING ON THE WORLDWIDE AGENDA

edorsed by the World Health Assembly ad the UNICEF Executive Board. The Global Strategy, while already more tha te years old, remais highly relevat to improvig ifat feedig practices today ad provides the overarchig policy framework ad major lies of actio eeded to protect, promote ad support appropriate feedig practices. UNICEF was istrumetal i the coveig of the 1990 ad 2005 global meetigs which led to the Ioceti Declaratios i those years. UNICEF s 2006 2015 Joit Health ad Nutritio Strategy 47, while still curret util 2015, will soo be superseded by a stad-aloe utritio strategy which is curretly uder developmet ad will reflect the latest evidece ad thikig o utritio ad effective itervetios, ad will also take ito accout sociopolitical, ecoomic ad climatic chages i a trasitioig world goig forward. The 2006 Joit Strategy reflects early iitiatio, exclusive ad cotiued breastfeedig as priority itervetios to achieve MDG4, but does ot detail strategic approaches to improvig breastfeedig practices. UNICEF s 2006 2013 Medium Term Strategic Pla (MTSP) also reflects icreasig exclusive breastfeedig as oe of the priority actios, targets ad idicators for the youg child survival ad developmet focus area. A ew MTSP is curretly uder developmet has exclusive breastfeedig as oe of the idicators, although it is ot yet fial ad may udergo more chages. I situatios of crisis, the UNICEF Core Commitmets for Childre (CCCs) 48 i Humaitaria Actio provide the strategic framework for respose, ad icludes IYCF as oe of 6 commitmets for utritio, emphasizig that the support, promotio ad protectio of breastfeedig is fudametal to prevetig uderutritio ad mortality amog ifats i emergecies ad layig out some key areas of actio o breastfeedig. I the major advocacy documets o utritio which UNICEF publishes, such as the 2009 Trackig Progress o Child ad Materal Nutritio 49 ad the 2013 Improvig Child Nutritio: a Imperative for Global Progress 50, breastfeedig is well reflected. Breastfeedig-specific advocacy publicatios have ot bee issued i recet years. I 2012 UNICEF published a assessmet of IYCF programmes i 65 coutries 51, ad has published a umber of techical ad programmatic guides ad tools o how to implemet breastfeedig strategies, icludig the Programmig Guide o Ifat ad Youg Child Feedig (2012) 52 ad the Commuity Ifat ad Youg Child Feedig Couselig Package (2012) 52. I most UNICEF programme coutries with a utritio programme, UNICEF s mai istrumet guidig coutry programmes, the Board-approved Coutry Programme Documet, reflects improvig breastfeedig as oe of the key actios. The World Health Orgaizatio (WHO) as the UN agecy madated for health, addresses breastfeedig primarily through its utritio departmet, but also i its work o ewbor ad child health. WHO ad UNICEF are joit owers of the 2002 Global Strategy o Ifat ad Youg Child Feedig ad WHO co-coveed the Ioceti cofereces with UNICEF. I 2012 the World Health Assembly approved a Comprehesive Implemetatio Pla for Materal, Ifat ad Youg Child Nutritio developed by WHO, which reflects Cousellig ad support for optimal breastfeedig (early iitiatio, exclusive breastfeedig for the first six moths ad cotiued breastfeedig up to two years of age or beyod) as oe of the effective direct utritio itervetios. The Pla has as oe of six global targets for utritio the icrease of exclusive breastfeedig to at least 50% by 2025, from the 2012 baselie of 37%. The six global targets were edorsed by the World Health Assembly i 2012. It is oted that breastfeedig is placed at the same level as utritio status idicators: the targets iclude child stutig ad wastig, aemia amog wome, low birthweight ad childhood obesity, as well as the exclusive breastfeedig target. This is a importat opportuity to focus attetio o results for breastfeedig. The World Health Assembly adopted the Iteratioal Code of Marketig of Breastmilk Substitutes i 1981, ad has sice adopted a umber of subsequet resolutios refiig ad updatig the global positio o the issue. WHO has authored several joit techical publicatios together with UNICEF, such as the Baby Friedly Hospital Iitiative (2009) 54, the Itegrated Ifat ad Youg Child Feedig Couselig Course (2007) 55 ad the Plaig Guide for Natioal Implemetatio of the Global Strategy for Ifat ad Youg Child Feedig (2007) 56 ad, together also with other agecies, the Ifat ad Youg Child Feedig Idicators (2008) 57, ad the Guidelies o HIV ad Ifat Feedig (2010) 58. WHO has also published various techical documets ad tools o breastfeedig, icludig the Ifat ad Youg Child Feedig Model Chapter for Medical Textbooks 59, the Breastfeedig Couselig UNICEF 23

course (1993; 2013 update i progress) ad various summaries of scietific evidece o breastfeedig, for example the scietific basis for the recommedatio of six moths for exclusive breastfeedig 60, 61. The World Food Programme (WFP), as the UN agecy madated to address huger with a focus o the provisio of food, has a Nutritio Policy (2012) ad Strategic Pla (2008 2013). These do ot refer to actios for breastfeedig, although there is referece to sesitizig mothers to good care practices. The page o the WFP website which refers to utritio for mothers ad youg childre xvi metios the importace of tacklig problems such as iappropriate feedig ad carig practices of childre. The UN High Commissioer for Refugees (UNHCR), as the UN agecy madated to address the protectio, rights ad wellbeig of refugees, addresses breastfeedig i its Public Health ad HIV Sectio s Guidig Priciples ad Strategic Plas (2008 2012) for HIV ad AIDS, Malaria Cotrol, Nutritio ad Food Security, Reproductive Health ad Water ad Saitatio icludes a strategic objective to establish ifat ad youg child feedig (IYCF) policies ad programmes, with a idicator o exclusive breastfeedig. UNHCR s headquarters is a active supporter of efforts to esure appropriate ifat feedig i emergecies. The World Bak s Jauary 2013 publicatio Improvig Nutritio Through Multisectoral Approaches 61 serves as a guidace documet for World Bak-supported iitiatives i coutries. It lists breastfeedig as oe of the utritio-specific priority itervetios for scalig up utritio, uder the headig of: Promotig good utritioal practices, which icludes optimal breastfeedig ad complemetary feedig (after 6 moths). Breastfeedig features promietly throughout the health sector chapter i particular. The documet otes that typical utritio activities fuded by the Bak iclude the promotio of optimal ifat ad youg child feedig practices (icludig breastfeedig ad complemetary feedig). The World Bak s 2010 publicatio Scalig Up Nutritio: What Will It Cost 63 provided cost estimates to deliver 13 direct utritio itervetios which fall uder 3 broad groups, with the followig group icludig breastfeedig: Behavior chage itervetios that iclude promotio of breastfeedig, appropriate complemetary feedig practices (but excludig provisio of food), ad proper hygiee, specifically hadwashig. It is assumed that the majority of these services are delivered oe-o-oe at the commuity level through platforms such as commuity utritio programs The World Bak estimated that $2.9 billio would be eeded aually for the behaviour chage itervetios. The costig of $7.50/year per child has bee based o promotioal activities for all the itervetios i the commuity utritio programmes, but does ot separate ifat ad youg child feedig. It does ot cover the promotio aspect of breastfeedig strategies comprehesively commuicatio usig media ad various other chaels is ot costed ad does ot cost actios for support professioal support for breastfeedig i health facilities ad commuity based couselig ad support services, icludig pre ad i-service traiig or the activities for protectio of breastfeedig (Code ad materity protectio). The costig therefore does ot reflect the full set of itervetios eeded to improve breastfeedig. The Bak s resource allocatio is determied through the coutry level projects that are submitted, which may or may ot iclude IYCF. The Bak oly reports o two utritio idicators to its Board: Vitami A supplemetatio ad a ew, composite idicator of the umber of wome ad childre reached with utritio services. Doors The UK s Departmet for Iteratioal Developmet (DFID) published Scalig Up Nutritio: The UK s positio paper o uderutritio i September 2011. The foreword of the paper highlights the fact that over the past 12 moths DFID has dramatically scaled up its work i the area [of utritio], ad states that i particular, we are puttig more moey ito specific services such as improvig vitami ad mieral itake ad supportig breastfeedig. The strategy emphasizes the focus o scalig up utritio-specific itervetios i the first 1,000 days, featurig support for breastfeedig promietly. It icludes breastfeedig i each of the examples of support to large coutries such as Nigeria, Bagladesh ad Idia. DFID has become oe of the major supporters of utritio programmes xvi http://www.wfp.org/utritio/mothers-childre 24 BREASTFEEDING ON THE WORLDWIDE AGENDA

addressig prevetio of uderutritio i recet years. The Europea Uio (EU) s 2011 Referece Documet: Addressig Uderutritio i Exteral Assistace features promotio of breastfeedig as oe of six areas of actio uder improvig health care i its Nutritio Framework for Actio ad behavior chage commuicatio o ifat ad youg child feedig as oe of three areas of actio to improve educatio. Breastfeedig is strogly reflected i the sectio o Improvig Nutritio through Health, which cotais a package of utritiospecific actios such as breastfeedig promotio, maagemet of severe acute malutritio ad vitami A supplemetatio. Key idicators of utritio beefits through health iclude early iitiatio of breastfeedig ad exclusive breastfeedig. The sectio o Improvig Nutritio through Geder features gedersesitive social protectio policies (e.g. targetig support to pregat ad lactatig wome to relieve their ecoomic burde durig the later stages of pregacy ad the breastfeedig period) as well as legal frameworks which protect wome s rights (e.g. workplace policies supportig breastfeedig). The sectio o Improvig Nutritio through Social Protectio has a idicator Breastfeedig is cotiued through first 12 moths of life i its key idicators of utritio beefits through social protectio. The chapter providig Guidace for Addressig Nutritio through Humaitaria Projects also has exclusive breastfeedig util 6 moths ad early iitiatio of breastfeedig as two of the six key utritio idicators i emergecies. The EU s strategic documet reflects breastfeedig promietly ad across various sectors. The EU has also become a major supporter of prevetive utritio programmes of late, icludig its iitiative o stutig reductio i ie Asia ad Africa coutries, i which breastfeedig itervetios are icluded. Its emergecy fudig for utritio teds to focus more o treatmet of severe acute malutritio. The US Govermet supports coutry-owed programs to address the root causes of uderutritio maily through the flagship programmes Feed the Future ad the Global Health Iitiative (GHI), i which utritio programs are itegrated. The US Govermet also reflects breastfeedig i its utritio assistace i emergecies through the Office of Foreig Disaster Assistace (OFDA). The GHI strategy paper xvii refers to breastfeedig ad promotio of appropriate feedig of ifats ad childre i the ewbor care arm of the strategic compoet Do more of what works: Rapidly scalig up the most relevat high impact itervetios... ad also to youg child feedig promotio i the child health arm. Breastfeedig is also metioed i the iovatio compoet, liked to itegrated prevetio ad treatmet of diarrheal disease ad peumoia. A major programme o materal, ewbor ad child health i USAID s Bureau for Global Health is MCHIP. Its utritio compoet promotes the Essetial Nutritio Actios, icludig early, exclusive ad cotiued breastfeedig. A key strategic documet 63 uderpiig USAID s materal ad child survival work reflects breastfeedig as oe of the high-impact itervetios ecessary to achieve child survival ad utritio goals, ad emphasizes early iitiatio ad exclusive breastfeedig. Feed the Future s utritio focus area emphasizes improvig utritio durig the critical 1,000 day widow of opportuity from pregacy to two years of age ad icludes ifat ad youg child feedig practices amog the idicators beig tracked to measure the impact of ivestmets. The US Govermet has ivested i a umber of projects ad iitiatives over the years which have featured breastfeedig ad complemetary feedig promietly i their objectives, strategies ad resources, icludig the Likages Project (1996 2006) xviii, the Ifat ad Youg Child Nutritio (IYCN) Project (2006 2012) xix ad ow the ew Stregtheig Parterships, Results, ad Iovatios i Nutritio Globally Project (SPRING) (ed 2011 2016) xx. SPRING supports the stregtheig ad scale-up of the coutry-cotextualized strategies for IYCF i its focus coutries, ad has a strog focus o social behavior chage commuicatio. May useful ad practical resources which support breastfeedig programmes were developed uder the Likages ad IYCN projects ad used i selected areas of various coutries for the specific project timeframes; the websites of both projects fuctio as major repositories for resources, tools, reviews ad other publicatios o breastfeedig ad ifat ad youg child feedig. The US Govermet also fuds a umber of istitutios ad NGOs which implemet breastfeedig programmes withi their portfolio of utritio ad child health, such as Save the Childre, Hele Keller Iteratioal, Joh Sow Iteratioal (JSI), PATH, World Visio, CARE ad others. xvii http://www.ghi.gov/resources/strategies/159150.htm xiii http://www.likagesproject.org/about/idex.php xix http://www.iyc.org/ xx http://www.sprig-utritio.org/ UNICEF 25

The Bill ad Melida Gates Foudatio (BMGF) has four mai programmes, icludig Global Policy ad Advocacy, Global Health Global Developmet, the latter icludig utritio ad materal, ewbor ad child health. The Foudatio features breastfeedig promietly i its 2011 Nutritio Strategy xxi, which highlights Promotig better breastfeedig practices as oe of the opportuities for utritio, ad states that the Foudatio is particularly iterested i ew approaches to improvig utritio for wome before ad durig pregacy ad for childre from birth to age 2 whe utritio is most critical to growth ad developmet ad lifelog health. This icludes ew approaches to esurig immediate ad exclusive breastfeedig for the first 6 moths of a child s life, followed by a trasitio to healthy complemetary feedig from 6 to 24 moths of age. Improvig breastfeedig practices is oe of four utritio focus areas, ad the Foudatio ivests i research to test ad evaluate ways to ecourage more effective breastfeedig practices through mass media, social etworks, materity ad marketig policies, ad iovative service delivery models ad by ehacig the kowledge ad skills of frotlie health workers. To date, the Foudatio s fudig support for utritio programmes has bee directed more towards product ad market based approaches, icludig large grats to GAIN, the sigle largest recipiet of BMGF fudig for utritio. The Foudatio is also fudig a three-coutry, 6-year learig iitiative called Alive ad Thrive (A&T) xxii implemeted by a cosortium of seve differet parters ad aimig to improve ifat ad youg child utritio by icreasig rates of exclusive breastfeedig ad improvig complemetary feedig practices. A&T s IYCF strategy 65 outlies i detail the comprehesive approaches take to protect, promote ad support breastfeedig. The strategy icludes improvig the policy ad regulatory eviromet, usig targeted ad evidece based advocacy ad buildig capacity for policy dialogue; secodly, household, commuity, health facility, ad mass media itervetios are supported to shape IYCF demad ad practice. Both supply side itervetios (e.g. traiig, supervisio, moitorig, creatig structures, etc) ad demad-side (iterpersoal ad mass commuicatio for behaviour ad social chage) are reflected. A&T has produced various resources ad tools o IYCF ad is coductig a rigorous evaluatio of its programmes to cotribute to the global evidece base o IYCF itervetios. The Childre s Ivestmet Fud Foudatio (CIFF) is a recet door to joi the child utritio field. Oe of CIFF s seve priority impact areas is huger alleviatio ad utritio. Its ladscape aalysis for this priority, coducted i 2009, features ifat ad youg child utritio as oe of five focus areas, with support for developmet of models to promote breastfeedig ad appropriate complemetary feedig at scale ad evaluatio of breastfeedig promotio i a coutry with high HIV prevalece. CIFF is developig a programme for prevetig uderutritio of childre uder two i Idia, but otherwise its mai ivestmet i utritio thus far has bee o the maagemet of severe acute malutritio, as well as some support for food fortificatio. No-govermetal orgaizatios I this sectio we focus o some of the mai NGOs which strogly focus o utritio ad/or o childre, recogizig that there are may others which also iclude breastfeedig amog various utritio ad health portfolios. The World Alliace for Breastfeedig Actio (WABA) xxiii is a umbrella body cosistig of idividuals ad orgaizatios cocered with the protectio, promotio ad support of breastfeedig worldwide. WABA s core parters are IBFAN, La Leche League Iteratioal, the Academy of Breastfeedig Medicie, Wellstart Iteratioal ad the Iteratioal Lactatio Cosultats Associatio. WABA is i cosultative status with UNICEF. Its visio is a world where breastfeedig is the cultural orm, where mothers ad families are eabled to feed ad care optimally for their ifats ad youg childre thus cotributig to a just ad healthy society ad its missio is to protect, promote ad support breastfeedig worldwide i the framework of the Ioceti Declaratios (1990 ad 2005) ad the Global Strategy for Ifat ad Youg Child Feedig through etworkig ad facilitatig collaborative efforts i social mobilisatio, advocacy, iformatio dissemiatio ad capacity buildig. Its goal is to foster a strog ad cohesive breastfeedig movemet, which will act o the various iteratioal istrumets to create a eablig eviromet for mothers, thus cotributig to icreasig optimal breastfeedig ad ifat ad youg child feedig practices. WABA has hosted ad orgaized World Breastfeedig Week xxiv globally o a aual basis i August sice 1992; this is oe of its mai activities. xxi http://www.gatesfoudatio.org/what-we-do/global- Developmet/Nutritio xxii http://www.aliveadthrive.org/about-us xxiii http://www.waba.org.my/ xxiv http://www.worldbreastfeedigweek.org/ 26 BREASTFEEDING ON THE WORLDWIDE AGENDA

The Iteratioal Baby Food Network (IBFAN) xxv, formed i 1979, is a coalitio of 273 ot-for-profit o-govermetal orgaizatios, icludig public iterest groups, workig aroud the world to reduce ifat ad youg child morbidity ad mortality through the protectio, promotio ad support for breastfeedig ad optimal ifat feedig practices. The Code is a strog focus area ad was the mai issue aroud which IBFAN was formed, with the pricipal aim of esurig that the marketig of baby food does ot have a egative impact o health. IBFAN describes itself as a sigle-issue orgaizatio. The Iteratioal Code Documetatio Cetre (ICDC) was established by IBFAN to provide a focus o the implemetatio of the Iteratioal Code. ICDC keeps track of Code implemetatio measures worldwide ad supports coutries i the draftig of atioal legislatio. IBFAN s mai website has a strog focus o the protectio aspect of actios for breastfeedig particularly the Code ad issue of breastmilk substitutes. I 2012 IBFAN produced a discussio paper o Scalig Up Breastfeedig/Ifat ad Youg Child Feedig Itervetios: What Will It Cost? 66, aimig to expad the costig beyod estimates for itegrated promotioal itervetios such as the World Bak s, ad suggestig that the eglect of itervetios to ehace breastfeedig has bee reflected i the lack of a global budget specifically for implemetig them. The costig covers selected itervetios for protectio, promotio ad support of breastfeedig, ad ackowledges that there is a lack of data about costs for itervetios. IBFAN also hosts the Global Breastfeedig Iitiative for Child Survival (gbics), a civil society-drive iitiative aimig to accelerate progress i attaiig the health-related MDGs, especially Goal 4, by scalig up early, exclusive ad cotiued breastfeedig. A major focus is the assessmet of the status of breastfeedig practices ad policies ad strategies i coutries through the World Breastfeedig Treds Iitiative (WBTI) xxvi, the results of which are iteded to be used to ifluece policies, for advocacy, for programme iitiatives etc. The WBTI uses combied data o breastfeedig practices (ot verified or edorsed by WHO or UNICEF at global level) together with the data reported by coutries o the status of policies ad programmes to give coutries a overall score. Save the Childre, with its focus o child health, utritio ad huger, poverty, protectio ad educatio, is a strog advocate ad supporter of breastfeedig. Its 2012 report A Life Free from Huger: Tacklig child malutritio 67 idetifies solutios that are prove to be effective, amog them direct itervetios, such as exclusive breastfeedig. The chapter o direct utritio itervetios features a dedicated sectio o IYCF, which reflects the full set of recommeded breastfeedig practices. It does ot cotai much detail o how breastfeedig practices should be improved, but focuses o the term promotio. The 2009 pla Hugry for Chage: a eight-step costed pla to tackle global huger 68 is structured aroud eight package compoets to address child huger, the first of which is breastfeedig promotio ad support. All the recommeded breastfeedig practices are preseted i the dedicated chapter o this compoet, ad the mai lies of actio are described, icludig health facility ad commuity couselig, commuicatio, ad support durig emergecies. The documet also features the Code ad materity protectio strogly. The package is costed, with a average of $18 per child per year for the breastfeedig compoet, comprisig seve breastfeedig cotacts, mass media ad utritio educatio o complemetary feedig. Iterestigly, the table o costig is the first time the documet has ay metio of complemetary feedig, although it is also metioed i several of the examples of programmes supported i the eight focus coutries. These examples also feature breastfeedig promietly. Save the Childre UK also published a advocacy documet dedicated to breastfeedig Superfood for Babies: How overcomig barriers to breastfeedig will save childre s lives 69, a global call to actio to rediscover the importace of breastfeedig ad to support mothers to breastfeed their babies especially i the poorest commuities i the poorest coutries. I emergecies, Save the Childre is oe of the mai implemeters of breastfeedig promotio ad support amog the NGOs supportig humaitaria respose o utritio. It also icludes ifat ad youg child feedig i its developmet focused programmes i coutries. Actio Agaist Huger (ACF) traditioally focused pricipally o humaitaria respose for utritio, but recetly has begu to address prevetio of uderutritio as well, icludig IYCF. xxv http://www.ibfa.org/all-about-ibfa.html xxvi http://www.worldbreastfeedigtreds.org/ UNICEF 27

The ACF-Iteratioal Policy /Strategy Paper: ACF iteratioal techical policy ad strategy 2012 2015 70 reflects breastfeedig as oe of the priority areas i the compoet Scalig up of itervetios to prevet ad treat uderutritio: prevetig uderutritio ad buildig resiliece. The ACF Iteratioal Strategy 71 refers to prevetig uderutritio but does ot metio ifat ad youg child feedig or breastfeedig. Similarly, the ACF website xxvii highlights the widow of opportuity for prevetig uderutritio, but metios oly treatmet of acute malutritio ad microutriets, ot IYCF or breastfeedig. ACF s coutry programme updates ad reports, however, frequetly feature actios i support of breastfeedig. Cocer Worldwide s programmes focus o educatio, livelihoods, HIV/AIDS, emergecies ad health, with utritio oe of the compoets of the latter. I terms of its utritio programmig, Cocer is oe of the pioeers of commuity based maagemet of acute malutritio ad this is its major focus. It is oe of the major implemeters of utritio respose i emergecies, also icludig ifat ad youg child feedig. Cocer has a Health Policy (2010) i which utritio is addressed. The Health Policy s oly metio of breastfeedig states that Cocer recogises the importace of breast feedig i child utritio ad will take steps to promote it withi the costraits posed by materal HIV/AIDS ifectio. However, reports of the agecy s programmes i coutries cotai may refereces to programmes to improve breastfeedig. Hele Keller Iteratioal (HKI) focuses o prevetig blidess ad reducig malutritio i the world. HKI features breastfeedig withi the Essetial Nutritio Actios 72 (ENA) framework i which all of the recommeded breastfeedig practices are icluded ad mai lies of actio to improve them are metioed o the website xxviii. The ENA framework, accordig to the website, features seve areas, the first of which is early iitiatio ad exclusive breastfeedig i the first six moths of life ad the secod optimal complemetary feedig from 6 moths of age with cotiued breastfeedig to 24 moths ad beyod. A key strategy of the ENA framework is to build a broad coalitio of advocates to promote messages ad services for the 7 actios. The ENA framework emphasizes reachig childre ad wome through existig programs i multiple sectors such as health, i local commuities ad through other relevat programs, ad has a strog focus o promotio of IYCF behaviours ad practices, via dissemiatio of messages through multiple chaels, as well as usig the techiques of behavior chage commuicatios which move beyod message dissemiatio to helpig idividuals ad commuities i makig the trasitio to healthier practices. Traiig of health providers ad commuity workers features promietly as a activity. The ENA framework has bee applied by HKI ad a umber of other agecies through projects maily i Africa ad Asia. The Global Alliace for Improved Nutritio (GAIN), a Swiss foudatio which supports public-private parterships to icrease access to the missig utriets i diets, has a ifat ad youg child utritio programme xxix. The programme s goal is to improve the health ad utritio of te millio childre aged 6 to 24 moths. Its strategy is to support public ad private parterships to reach ifats i low-icome families with multiutriet supplemets ad high-quality ad affordable utritious foods that complemet breast milk from six moths of age. The descriptio of approaches icludes a metio of appropriate marketig i support of breastfeedig but GAIN s focus is o market-based approaches for food supplemets ad products for complemetary feedig. A press release i February 2013 xxx states that GAIN promotes early iitiatio of breastfeedig, exclusive breastfeedig through age 6 moths ad cotiued breastfeedig through at least age 24 moths with the itroductio of appropriate, adequately utritious complemetary foods from 6 moths of age. A umber of similar statemets o support for breastfeedig ca also be foud, but the programmes ad iitiatives implemeted by GAIN do ot i practice seem to feature breastfeedig, as per the descriptios of its programmes o its website. IYCF policies/strategies i coutries This sectio briefly outlies the mai fidigs from three differet multi-coutry aalyses related to the policy eviromet for IYCF. Each was coducted i the period 2009 2011. WHO assessed some aspects of IYCF policy ad programmig as part of a broader review of utritio policies (119 coutries), UNICEF assessed IYCF programmes (65 coutries) ad IBFAN focused i particular o breastfeedig (40 coutries). Also highlighted are major fidigs related to policy eviromet, xxvii http://www.actioagaisthuger.org.uk/ xxviii http://www.hki.org/reducig-malutritio/essetial-utritio-actios/ xxix http://www.gaihealth.org/programs/gai-ifat-ad-youg-childutritio-program xxx http://www.gaihealth.org/press-releases/ gai%e2%80%99s-respose-ibfa-press-release-who-decisio 28 BREASTFEEDING ON THE WORLDWIDE AGENDA

MORE COUNTRIES HAD IYCF POLICIES THAN STRATEGIES AND PLANS OF ACTION advocacy ad leadership from two differet reviews of breastfeedig programmes spaig 15 coutries, coducted by AED ad UNICEF from 2007 2009. I 2009, WHO xxxi, coducted a review of utritio policies i coutries, receivig resposes from 119 coutries, icludig idustrialized coutries 73. The review icludes a sectio reviewig policies o materal, ifat ad youg child utritio, comprisig resposes from 104 coutries. Amog these, 69% idicated that their coutry had a policy coverig IYCF, with 57% idicatig the policy had bee officially adopted. Policy cotet was assessed to some extet, otig reflectio of the feedig of low birth weight ifats (52% of coutries), ifat feedig i emergecies (oly 31% of coutries) ad HIV ad ifat feedig (41% of coutries, with 55% of Africa coutries reportig policies o this). The survey assessed implemetatio i coutries of at least three of four priority actios of the global IYCF strategy (the Code, materity protectio, BFHI ad traiig o IYCF couselig). The results by regio showed a rage from less tha 40% of coutries i Easter Mediterraea (EMR) implemetig at least three of the priority areas to over 70% i the Europea regio. The survey also asked about implemetatio of selected itervetios, icludig promotio of breastfeedig (98% of coutries, with the vast majority at atioal scale which is ulikely ad difficult to verify, as few coutries have moitorig systems that would eable them to report o scale of actios) ad the BFHI, where few coutries provided detailed iformatio. I additio, the WHO survey assessed the presece of various utritio idicators i atioal surveys i coutries, icludig exclusive breastfeedig. It was foud that oly 62% of the 113 coutries which respoded reportig o the exclusive breastfeedig idicator, ragig from 30% i the Europea regio to 100% i EMR. The report also has a sectio o the Code, reportig that 71% of the coutries had a legal measure, amog which 80% had a full measure. The WHO survey icludes a case study etitled Breastfeedig i a Globalized World: a Public Health Success Story. It icludes the statemet The implemetatio of a series of policies ad programmes to protect, promote ad support breastfeedig over the past 30 years has led to remarkable icrease i breastfeedig practices measured at global level a statemet icogruous with the stagat treds of exclusive breastfeedig at global level. As evidece supportig this statemet, figures are cited o the icrease i media duratio of breastfeedig i 36 coutries with tred data, icreases of exclusive breastfeedig i 29 coutries i the Americas regio ad 13 coutries with showig gais of more tha 25 percetage poits. It the goes o to state that the proportio of ifats breastfed for the six moths recommeded by WHO is low, idicatig a importat area for policy ad programmatic actio. The IYCF policy aspects of UNICEF s 2010 2011 assessmet of IYCF programmes i 65 coutries xxxii foud that overall, more coutries had IYCF policies tha strategies ad plas of actios. Approximately 84% of the coutries had policies (stad-aloe or itegrated), 60% had strategies ad oly 48% had plas of actio. The key IYCF practices that are reflected i most coutry s atioal IYCF policy were exclusive breastfeedig (85% of coutries) ad cotiued breastfeedig from 6 23 moths (76% of coutries), while early iitiatio of breastfeedig appeared i oly 68% of the coutries policies. The assessmet reported o the whether ie key actio areas were reflected i the policies, icludig the BFHI (i the policies of 73% of coutries), the 10 Steps to Successful Breastfeedig i materities (69%), the Code (66%), materal utritio (55%), commuity actios (87%), mother support groups (47%), behavior chage commuicatio (52%), HIV ad ifat feedig (61%) ad IYCF i emergecies (43%). The UNICEF assessmet framework also addresses the status of actios i health services, at commuity level, commuicatio, IYCF i the cotext of HIV ad emergecies, additioal complemetary feedig itervetios i multiple sectors ad moitorig ad evaluatio. Moitorig of the performace of IYCF itervetios, i additio to outcomes i terms of practices, is a crucial aspect i gaugig commitmet to IYCF. The UNICEF assessmet cotais questios o geographic coverage (umber of districts) of health facility ad commuity based IYCF services, coverage of traiig for health providers ad commuity workers ad populatio coverage with itervetios at health facility ad commuity levels. Just uder two-thirds of the surveyed coutries reported o the percetage of districts i which health facility IYCF cousellig was stated to take place, with a wide rage of coverage from 2% to a reported 100%, with a average of 31%. A similar xxxi This report was oe of the backgroud documets at the 65th WHA whe the utritio targets ad the implemetatio pla were discussed. A fial versio does ot appear o the website. xxxii The coutries assessed were i the 6 regios of Easter ad Souther Africa, West ad Cetral Africa, South Asia, Middle East ad North Africa, Cetral ad Easter Europe/Commo wealth of Idepedet States ad East Asia ad Pacific. UNICEF 29

proportio (just uder two-thirds) of the coutries idicated that health workers had bee traied o IYCF cousellig sice 2006. Of these, just over half of the coutries were able to report o the proportio of total applicable health workers who had bee traied, with a further 16 coutries reportig o the umbers of workers traied but uable to provide a deomiator. The proportio traied i the 24 coutries was geerally very low, with a average of just 6% ad a rage from 0.1% to 82%. The assessmet was uable to obtai resposes from the coutries o populatio coverage of IYCF couselig, as they do ot collect this iformatio i the health system. Regardig commuity based IYCF itervetios, aroud half of the coutries were able to idicate the geographic coverage of commuity-based IYCF activities i terms of the proportio of districts with these services. The rage was wide, from 0.5% of districts to a reported 100%, with a average of 60%, which is ecouragig. Oly a third of the coutries were able to report o the proportio of commuity health workers traied o IYCF cousellig sice 2006. The average was 30% (ragig from 2% to 100%). A further seve coutries reported the umber traied but were uable to provide a deomiator. A rapid sca of some examples of coutry IYCF policies ad strategies i Africa ad Asia reveals that very few iclude ay process idicators for IYCF itervetios, ad idicators for geographic ad populatio coverage was ot foud i ay coutry s strategy. This is a major gap i atioal systems, which seriously affects coutries ability to make decisios o improvig programmes that are data-iformed. IYCF practices are geerally used as proxies for itervetios, but data o practices is collected ifrequetly ad usually oly at atioal level; a programme maager eeds much more iformatio tha this to desig ad target itervetios effectively ad track their progress. A lack of systems to measure the performace of itervetios ad services also traslates to reduced commitmet, priority ad istitutioalizatio of the actios. The fact that there are o global ad atioal reportig requiremets ad systems for the status of itervetios may also cotribute to the lack of awareess of which itervetios should be implemeted, which was raised by some of the stakeholders i the survey (see the sectio o Ideas i the survey results below). The IBFAN World Breastfeedig Treds Iitiative (WBTI) has bee iitiated i 82 coutries, with 51 reported to have completed their assessmets to date. It assesses whether a atioal IYCF/ breastfeedig policy has bee officially adopted/ approved by the Govermet, whether the policy promotes exclusive breastfeedig i the first six moths ad cotiued breastfeedig up to two years ad beyod, whether a atioal pla has bee developed with the policy ad whether the pla is adequately fuded. It also asks whether there is a atioal coordiatig body or mechaism for IYCF that fuctios. A summary of the results of the assessmet i 40 coutries published i 2012 74 revealed that 82% of the 40 coutries report havig a policy, but oly 62% have a atioal pla ad oly 28% report that the pla is adequately fuded. The WBTi framework also addresses the BFHI, the Code ad materity protectio, health ad utritio care systems, mother support ad commuity outreach, iformatio support, ifat feedig ad HIV, ifat feedig durig emergecies ad moitorig ad evaluatio. The WBTI did ot attempt to assess the scale of programmes other tha to ask do all wome have access to IYCF services ad do IYCF services have atioal coverage, with respose optios beig yes, to some degree or o. The WBTi, although it states that it tracks ifat ad youg child feedig programmes, does ot assess the full set of evidecebased itervetios for improvig complemetary feedig i all settigs, coverig oly actios for the promotio of improved practices. The Six-Coutry Review of Breastfeedig Programmes 75 coducted by AED ad UNICEF oted that whe the iteratioal commuity were see to be givig greater priority i the late 1990s owards to other health ad developmet priorities as compared to breastfeedig, some coutries did so as well. It was also oted that the WHO/UNICEF 2002 Global Strategy for IYCF ifused ew eergy ad prompted coutries to reexamie their strategies. I may of the coutries reviewed, respected, trustworthy champios have dedicated decades to the protectio, promotio, ad support of breastfeedig. Their evidece-based advocacy, passio, persistece, ad persuasive skills helped move the ageda atioally. Key lessos leared were captured by the review. The review s coclusios reaffirmed that is importat for all global ad coutry utritio iitiatives emphasize ot oly 30 BREASTFEEDING ON THE WORLDWIDE AGENDA

breastfeedig promotio, but also support ad protectio. Both exclusive breastfeedig up to 6 moths ad cotiued breastfeedig after 6 moths lead to importat health beefits ad should be emphasized to measure atioal progress. The review of large-scale commuity based breastfeedig programmes 76 i te coutries recofirmed the critical role of leadership, parterships, proof of cocept, ad resources facilitate programme scale-up. Political leadership ad utritio champios helped to garer commitmet ad resources. Pilot activities that demostrated proof of cocept, documeted programme strategies, ad dissemiated iovatios, results, ad practical tools led to programme expasio as did adequate ad sustaied fudig. I some of the reviewed coutries it was demostrated how breastfeedig practices ca chage over a relatively short period ad eed cotiued reiforcemet to be sustaied as egative chage ca also occur i a short time. We also highlight the fidig that multiple programme frameworks offer opportuities for commuity-based breastfeedig promotio ad support, ad improved breastfeedig practices add value to all of these programmes. Also importat is the fidig that effective commuicatio ad advocacy are vital to set policy priorities, ifluece commuity orms, ad improve household practices. SUMMARY AND ANALYSIS How promiet is breastfeedig i the strategic frameworks of selected agecies ad i the strategic frameworks of coutries? It ca be see that all of the utritio global iitiatives do reflect breastfeedig quite strogly i their strategies ad other documets, ad there are good advocacy opportuities to raise the attetio ad commitmet to breastfeedig withi the iitiatives. Despite the compellig evidece o the importace of breastfeedig for survival, the child survival iitiatives appear to provide a more toke metio of breastfeedig but potetially also afford opportuities for advocacy for breastfeedig. Amog the UN agecies, WHO ad UNICEF joitly reflect global leadership i terms of policy, strategy ad programme frameworks ad resources, which address breastfeedig comprehesively. The World Bak also reflects breastfeedig strogly i its guidace ad costig aalysis. Breastfeedig features strogly i the majority of the doors strategic frameworks that were reviewed. Although less promiet i the US Govermet s flagship health ad utritio frameworks, there have bee major USG-fuded projects focusig o ifat ad youg child feedig over the years. Amog the NGO documets ad websites reviewed, a wide rage of strategic frameworks ad policies are foud, from sigle-issue campaigig ad a focus o the protectio of breastfeedig i the IBFAN etworks, through strog reflectio i strategic frameworks, advocacy ad programmig by Save the Childre, iclusio i developmet ad emergecy utritio portfolios ad resposes (HKI, ACF), to some political metio of commitmet but o reflectio i strategies ad programmes (GAIN). 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. The three recet assessmets of IYCF policies ad programmes foud that o average more coutries (aroud 78%) had IYCF policies tha atioal plas of actios (55%). At the same time, it was foud that oly 62% of the 113 coutries which respoded to the WHO policy survey say they report o the exclusive breastfeedig idicator i atioal surveys, a result perhaps skewed by the resposes of idustrialized coutries.the assessmets showed oly moderate performace i terms the presece of recommeded programme compoets i the strategic frameworks, with may gaps still to be addressed. They also foud major gaps i terms of the status of actios related to the mai programme compoets, with oe of the assessmets providig iformatio o itervetio coverage ad scale of programmes. This poits to a eviromet that may be characterized as relatively policy-rich ad geerally implemetatio-poor. Are all recommeded ad importat breastfeedig practices reflected i strategic frameworks? Cogizat of the full set of recommeded key breastfeedig practices ad the eight core idicators that were agreed globally to measure the status of these practices 77, it was oted that 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 UNICEF 31

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 focus o exclusive breastfeedig may cotribute to the tedecy i the global policy commuity to separate breastfeedig ad complemetary feedig ( promotig exclusive breastfeedig for the first six moths is about survival; products for complemetary feedig from 6 23 moths are about reducig stutig ), placig these vital ad coected issues at odds with oe aother. The 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 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 78. Do strategy frameworks reflect a comprehesive approach to improvig breastfeedig practices? The cotiuig predomiace of promotio of breastfeedig i may of the frameworks ad statemets stood out i the aalysis. The term promotio is ofte iteded to imply the full set of actios ad itervetios to improve breastfeedig, but as such it is a misomer, as promotio is about messagig, social marketig ad iformatio dissemiatio. This may be due to the domiat otio that improvig breastfeedig is primarily behavioural ad a lack of uderstadig of the role of professioal ad lay support ad the importace of legal frameworks ad istrumets for protectig breastfeedig. Professioal support fulfills a differet fuctio tha promotio, i that it cocers practical ad skilled assistace to mothers to start ad sustai breastfeedig after delivery, the solvig of breastfeedig problems ad ogoig couselig ad practical help durig lactatio. Itervetios deliverig skilled support ad promotioal activities complemet each other ad eed to go had i had. such that they focus more o messagig ad do ot ivest i the health system structures to istitutioalize the delivery of professioal breastfeedig support ad couselig by skilled staff (whether health providers or lactatio couselors) ad the routie moitorig of itervetio coverage ad quality. Similarly, ivestmet i systems ad structures for commuitybased couselig ad support at scale also lags, as well as effective systems to eforce regulatory istrumets for the protectio of breastfeedig. The ladmark World Bak costig of utritio itervetios, reflectig oly behavior chage itervetios to promote breastfeedig, mirrors this tedecy. O the other had, we see a more comprehesive reflectio of approaches to improvig breastfeedig across a rage of orgaizatios, icludig UNICEF, WHO, the World Bak, the EU, A&T, Save the Childre ad IBFAN, as well as the IFE Core Group. Is there cosesus o measurig the status of IYCF programmes? The aalysis of the two mai exteral assessmets of breastfeedig/iycf programmes i coutries (IBFAN s WBTi ad UNI- CEF s IYCF programme assessmet) reveals a lack of cosesus o measurig the performace of programmes. While there is some commo groud, the two exteral assessmet frameworks diverge o which programme compoets should be assessed ad which key process idicators should be measured. A particularly weak lik is the assessmet of the populatio coverage of IYCF itervetios, icludig couselig/support ad commuicatio: abset i the former ad ot possible to collect i the latter due to lack of atioal moitorig systems. Global cosesus o a harmoized ad comprehesive set of idicators to measure the performace of IYCF programmes, icludig geographic ad populatio coverage, is eeded. Accoutability to report o their status should cotribute towards icreasig the commitmet ad priority for breastfeedig ad complemetary feedig. It will therefore be crucial to advocate for the moitorig frameworks of coutry strategies ad atioal iformatio systems to be updated to iclude this set of idicators. The predomiat use of the term promotio may have the effect of shapig the strategies of orgaizatios ad coutries, 32 BREASTFEEDING ON THE WORLDWIDE AGENDA

A global policy commuity is more likely to geerate political support for its cocer if it is cohesive, well-led, guided by strog istitutios, ad backed by mobilised civil societies; if it agrees o solutios to the problem ad has developed frames for the issue that resoate with political leaders; if it takes advatage of policy widows ad is situated i a sector with a strog global goverace structure; ad if it addresses a issue that is easily measured, is high i severity, ad has effective itervetios available. Jeremy Shiffma, Geeratio of political priority for global health iitiatives: a framework ad case study of materal mortality, Lacet, October 13, 2007 KEY FINDINGS OF STAKEHOLDER SURVEY ACTORS How do the actors i the global policy commuity for breastfeedig as represeted by the wide cross-sectio of stakeholders cosulted durig this survey rak the political commitmet to breastfeedig? Stakeholders said the rise of child uderutritio ad stutig o the global ageda has ot traslated ito greater visibility for breastfeedig. Most stakeholders raked political priority for breastfeedig as average to low (see Figure 7 below), despite it beig a essetial pillar of ifat ad youg child feedig programmes. Relative to its importace, it s just udervalued said oe respodet. We also see a wide rage of views o commitmet, which may also reflect the lack of policy commuity cohesio. FIGURE 7 Political priority for breastfeedig: relative to its importace, it s just udervalued Stakeholder rakig of political commitmet for breastfeedig relative to its potetial impact to save lives Highest Commitmet 10 9 8 1 Lowest Commitmet 7 6 5 4 3 2 1 3 4 5 4 13 8 6 The coloured circles represet stakeholders rakig of political commitmet for breastfeedig o a scale of 1 (lowest commitmet) to 10 (highest commitmet). Forty-four respodets provided ratigs. UNICEF 33

Policy commuity cohesio Brigs etworks together, coects differet types of orgaizatios Cohesio ad cosesus amog a policy commuity are essetial i gaiig tractio aroud a issue ad i advacig a ageda. I its assessmet of the degree of cohesio ad idetificatio of the major cotetious issues, the stakeholder survey throws the spotlight o a situatio marked by a serious lack of cohesio ad cosesus. All respodets coveyed their commitmet to promote ifat ad youg child feedig as a critical child survival ad developmet itervetio. But they also idetified a set of issues that have fractured the policy commuity alog ideological, professioal ad geder divides. Oe of the big issues which stood out amog the fidigs of the stakeholder survey is the cotetiousess ad stark disagreemet amog differet costituecies o egagemet with the private sector. This disagreemet has of late had farreachig ramificatios, such as the public statemet from IBFAN that i view of the cocers about the role of busiess i SUN, IBFAN ad may of its allies caot support the SUN iitiative 79. This level of disagreemet ca oly hamper the ageda for breastfeedig, creates a distractio from the cetral issues ad cotributes to prevetig progress by the global policy commuity. Stakeholders for breastfeedig are polarized. There s the more militat, ati-corporate commuity, who perceive themselves as a commuity because their covictios are so similar. O the other side, you ve got middle-of-the-road orgaizatios that absolutely see breastfeedig as a cetral core compoet of a good utritio strategy, but are more willig to work with the private sector. There s o outward fightig, but the commuity is ot aliged ad cohesive. There s o good reaso for that. (S10) The biggest disagreemet the elephat i the room (S6) reflects diverget positios o the role of private sector food compaies i reducig ifat ad youg child uderutritio. The debate has gaied urgecy as UN agecies, the World Bak ad other global actors icreasigly egage i public- private parterships perceived as crucial to achievig the MDGs. Some respodets such as this NGO represetative said it was essetial to collaborate with food compaies to reduce stutig: The virulet breastfeedig advocates are ow pushig back that o compay ca be ever be trusted o complemetary foods because they ll disturb breastfeedig. They re so igraied i their promotio of breastfeedig they ve lost a sesible view of what it takes to keep a child well-ourished from zero to 24 moths. That icludes optimal complemetary feedig ad usig fortified products provided i some cases by the local private sector, maybe multiatioals. You have this part of our utritio commuity that is dead set agaist ay ivolvemet of the private sector. It s really creatig problems. (S6) Civil society advocates viewed egagemet with food compaies i a very differet light, warig that private gais beefitig shareholders should ot be cofused with public health goals. They called for coflict of iterest policies to be put i place to guard agaist this. Otherwise, you could have formula compaies beig part of SUN before you kow it! as oe respodet put it. (S11) States [ ] have a duty to support exclusive breastfeedig for six moths ad cotiued breastfeedig, combied with adequate complemetary foods, util the secod birthday of the child. accordig to the UN Special Rapporteur o the Right to Food 80. Watchdog groups perceive they are shoulderig more tha their fair share of resposibility to esure govermets fulfill this duty i the absece of a clear breakdow of accoutabilities amog parters: Oe big barrier is clarificatio of the roles of the actors i protectio, promotio, ad support of breastfeedig, ad holdig them accoutable for actually fulfillig these roles. (S11) Several wome stakeholders said professioal biases i the utritio commuity were also impactig breastfeedig programmes, otig that ivestmet i utritio has largely bee focused o treatmet of acute malutritio with a heavy focus o utritioal products: 34 BREASTFEEDING ON THE WORLDWIDE AGENDA

Nothig uited respodets more tha the logig for leadership to advace political priority for breastfeedig practices The utritio world is lookig for a magic bullet through products. You have ready-to-use food, microutriet powder, fortified complemetary food, ad very little attetio is paid to breastfeedig. With the products ad microutriets, me are more i the lead. Breastfeedig ad ifat feedig is a woma s world. (S7) At the global level, there are a lot of me i seior-level discussios. The fewer wome ivolved, the more breastfeedig gets forgotte. (S6) Uderstadig how these dyamics are ifluecig prioritizatio of breastfeedig withi the utritio stakeholder orgaizatios ad parterships is essetial goig forward. There is also a urget eed for a middle voice, with strog leadership ad coveig ability, to facilitate greater cosesus ad commo groud to move forwards the ageda for breastfeedig. Leadership ad guidig istitutios The presece of idividuals capable of uitig the policy commuity ad ackowledged as a particularly strog champios for breastfeedig The effectiveess of orgaizatios, or coordiatig mechaisms, with a madate to reduce materal ad child uderutritio Global leadership for utritio i geeral has udergoe a major shift i the last few years, with the emergece of a global movemet behid which may stakeholders have rallied ad a leadership group aims to improve coherece, provide strategic oversight, improve resource mobilizatio ad esure collective accoutability. Cogizat of this cotext, the stakeholder survey assessed perceptios o the extet to which global leadership for breastfeedig is felt to be preset, ad foud a otable absece of strog leadership over the past two decades. Nothig uited respodets more tha the logig for leadership to advace political priority for breastfeedig practices. Leadership always trumps everythig for me. (S3) A champio of breastfeedig two decades ago UNICEF Executive Director James Grat is still the referece poit for idividual leadership. As oe respodet oted: James Grat, UNICEF Executive Director (1980 1995) was a recogized global champio for breastfeedig. UNICEF 35

Siloed programmig was flagged as a key challege Leadership is the umber oe factor i buildig political ad door support. Whe James Grat took o the Baby Friedly Hospital Iitiative, that leadership was trasformative. (S1) A civil society advocate framed the importace of leadership differetly: It s about brave people committed to huma rights who uderstad political, social, ecoomic determiats ad do t thik Plumpy ut is goig to save the world. (S11) Stakeholders could t idetify ay high profile global breastfeedig champio active today. While recogizig the techical cotributios made by WHO ad UNICEF as guidig istitutios, some respodets questioed the curret level of commitmet at the highest levels of these orgaizatios: Globally, both WHO ad UNICEF project other priority areas much more tha breastfeedig. Budget allocated does ot match priority statemets. (Q3) A US stakeholder commeted USAID leadership had also faltered: USAID has bee very focused o private sector egagemet ad iovatios i techology. Those are the two big tredy areas of iterest, ad breastfeedig fits i either oe of them. It s left o its ow as a orpha with o real strog costituecy. (S10) Doors Doors play a critical ad syergistic role to promote political priority for global utritio ad health iitiatives through resources ad advocacy. As the fiacial crisis cotiues to grip the developed world, door aid is also costrictig after a decade of strog growth. Net overseas developmet aid fell i 2011 the first drop sice 1997 takig iflatio ito accout, accordig to the OECD 81. The utritio slice of this global assistace cotiues to be tiy. The Uited States, a key door, devotes less tha 1% of its foreig assistace budget to improve utritioal outcomes 82. Accordig to the World Bak, despite potetially very high returs o ivestmet, utritio has bee a forgotte MDG ofte urecogized, rarely acted upo, ad grossly uderfuded 83. This fudig shortfall weighs heavily o all the costituecies cosulted, icludig those of the guidig istitutios. A UN staff member summarized the situatio this way: There are virtually o resources at the iteratioal ad atioal level for breastfeedig support, despite the abudace of evidece of its impact o child survival. (Q1) Several wome respodets made a coectio betwee ambivalet attitudes towards breastfeedig i door coutries, ad levels of fudig ad political support: A lot of doors are very Wester. They see breastfeedig as a choice for mothers to make. Some doors basically said my family formula fed, ad are you sayig I did the wrog thig by my child? It s a huge, loaded issue because people become very defesive about what they could ad could t do. (S8) Aother added: We are fightig a uphill battle if we fail to chage attitudes ad practices i the West/developed coutries. (Q4) Fragmeted programme resposes Fragmetatio amog the global utritio commuity was a persistet theme i the 2008 Lacet Nutritio Series 84. The stakeholder survey idetified a ogoig issue of fragmeted ad siloed programme resposes hamperig progress for breastfeedig. Siloed programmig was flagged as a key challege, otably i guidig istitutios: I the global orgaizatios, UNICEF ad WHO, utritio programmes are orgaizatioally separate from MNCH programmes, which is a real barrier to developig a effective strategy ad promotig it. That s a problem that eeds to be addressed by force. Somebody eeds to make such a loud oise that UNICEF ad WHO two key agecies have o choice but to develop a itegrated pla. (S13) Fragmeted programmig ca also impact emergecy resposes, where there ca be cofusio betwee health ad 36 BREASTFEEDING ON THE WORLDWIDE AGENDA

utritio professioals about who is leadig ad what is techically required. (S8) Voices callig for cross-cuttig approaches to global health 85 ad utritio are growig: the time for silos is past those workig i utritio, food security, agriculture, water ad health must joi together to coquer the cause of oe third of child deaths worldwide uderutritio 86. Civil society mobilizatio Extet to which grassroots orgaizatios have mobilized to press iteratioal ad atioal political authorities to address breastfeedig practices No-Govermetal Orgaizatios (NGOs) ad civil society orgaizatios have played a vital role to protect, promote ad support breastfeedig practices. Whether it s ruig Mother Support Groups, drivig advocacy, moitorig the formula idustry or supportig breastfeedig i emergecies, they are preset o may frots. the problem. (S23) Aother oted the difficulty of assessig the impact of a iitiative ot liked with a clear advocacy strategy. (Q13) A stakeholder based i East Asia commeted: World Breastfeedig Week is ice, but some coutries feel Okay, if I do that week, I ve doe my part. It s ot helpig us i a way. (S26) A UNICEF Represetative i a emergig Asia ecoomy said World Breastfeedig Week could t compete with the very sophisticated ad log-term campaig the formula compaies have goig here. (S19) May respodets said advocacy eeds to be cotiuous ad expressed a strog eed for global, regioal ad coutry advocacy plas to guide ad uify actio. A UNICEF office battlig low breastfeedig rates i South Asia said their greatest eed was for evidece-based breastfeedig advocacy. (Q19) Several respodets oted the cotributio IBFAN (Iteratioal Baby Food Actio Network) ad other watchdog groups have made (S16, S21) but other felt their message was too egative: For a log time, breastfeedig has bee about ati-formula as opposed to beig about breastfeedig. That s perhaps a harsh judgmet but sometimes I see a lot of reactio ad ot much pro-actio. (S3) World Breastfeedig Week The World Breastfeedig Alliace (WABA) hosts World Breastfeedig Week 87, held each August sice 1992, with support from WHO ad UNICEF ad other parters. While this study could t idetify ay formal evaluatios of the advocacy iitiative, stakeholders shared a rage of opiios. O the plus side, coutries such as the Philippies use World Breastfeedig Week as a major health promotio opportuity. (S8) Most assessmets of World Breastfeedig Week were more critical: A Africa-based respodet said they did ot get value for moey because oe week was too small scale give ISSUES Importace of the issue Size of the potetial impact of breastfeedig relative to other itervetios, as idicated by objective measures, such as mortality levels, utritio status, log term effects Compellig evidece is available o the may beefits of breastfeedig for child survival, utritio status ad developmet, as outlied above. Breastfeedig does ot lack evidece for its importace ad its umerous ad wide-ragig beefits, ad these are quite well-kow. Ad yet, despite this compellig evidece, global rates of breastfeedig have remaied relatively stagat i the developig world ad commitmet low. As oe stakeholder put it: With such compellig evidece shame o us [the global policy commuity] for ot havig bee able to make the case for breastfeedig. The role of advocacy i cotributig to the much eeded shift i this situatio is clear: the compellig evidece eeds to be more effectively framed ad deployed so that it appeals to UNICEF 37

Wome must ofte overcome may barriers to exclusively breastfeed their ifats. This baby girl ad her mother live i a makeshift shelter followig the 2010 earthquake i Haiti, where they receive basic services icludig breastfeedig couselig for mothers. political ad policy leaders ad leads to greater attetio, commitmet ad actio for breastfeedig. Evidece correctly placed i a advocacy strategy ca chage the world. (S13) Ifluece of the HIV epidemic Oe of the major factors which has affected the global policy commuity s ability to clearly ad uequivocally advocate for breastfeedig has bee the HIV pademic. A umber of stakeholders referred to the serious impact of the HIV/AIDS pademic o breastfeedig programmes i the past two decades, especially i Sub-Sahara Africa where the disease struck hardest: We were doig great work o breastfeedig i the 70s ad 80s. The Baby-Friedly Hospital Iitiative did t go far eough ito the commuity, but there were focused set of actios that could be take. Whe HIV hit the world stage, all of that stuff stopped. Everythig aroud breastfeedig, all the exteral dollars, all the fears were about HIV trasmissio. (S3) A research group oted cofusig messagig by the UN i relatio to HIV ad ifat feedig had udermied advocacy: It may take years for atioal programmes ad health services to overcome the cofusios created i the wake of the WHO s 2001 ifat feedig recommedatios. It may take eve loger to retur breastfeedig to its social positio as the oly way to feed a ifat, as coditio for child survival ad as a fudametal commitmet of motherhood 88. 38 BREASTFEEDING ON THE WORLDWIDE AGENDA

NOTHING WORRIED STAKEHOLDERS MORE THAN THE THREAT FORMULA COMPANIES POSE TO BREASTFEEDING Other stakeholders saw more positive outcomes, facilitated by WHO s 2010 recommedatio that all mothers, icludig those who are HIV positive, breastfeed their babies 89 : It s a great time [to icrease political commitmet] because the HIV issue has subsided. There s less cotroversy aroud that. If we ca get some real iovatio aroud how we advocate ad get commitmet, it would really make a measurable impact. (S3) Tractability Extet to which there are effective itervetios to protect, promote ad support breastfeedig i developig coutries Policy makers are more likely to act o issues for which there are credible, evidece-based itervetios 90. Achievig optimum breastfeedig requires multiple itervetios: to promote behaviour ad social chage, to provide skilled professioal support ad peer or commuity based support i may settigs, ad to afford protectio agaist the marketig of breastmilk substitutes ad i favour of materity leave ad workplace policies. Achievig this at the scale of a commuity, a metropolis or a atio poses challeges. You rarely hear a woma sayig: I do t wat to breastfeed. You hear wome sayig: I ca t breastfeed. Our actios eed to make the world a more breastfeedigfriedly place. (S21) Stakeholders discussed a umber of issues related to how programmig ad commuicatio for breastfeedig eeds to be tailored to the lives of wome i differet cotexts i the 21st cetury: workig mothers i emergig ecoomies; mothers ad families still exposed to strog traditioal beliefs, iflueces ad social orms i some settigs, particularly rural Africa ad Asia, o the oe had, ad iflueced by cosumer priorities ad the private sector o the other, particularly i rapidly urbaizig settigs. They also discussed the rapid peetratio of cellphoe techology ad social media ad its relatively utapped potetial for commuicatio ad advocacy o breastfeedig. They emphasized that more of the same was ot goig to cut it: traditioal approaches to programmig, commuicatio ad advocacy eeded to be fudametally overhauled to make it curret, relevat ad resoat. This liks to the theme of recastig the arrative that emerges strogly from the arrative. Cotetiousess Extet to which addressig the issue icites oppositio Nothig worried stakeholders more tha the threat formula compaies pose to breastfeedig practices i low ad middleicome coutries. I 1982, UNICEF Executive Director James Grat made a presciet statemet about the growig impact of formula compaies o breastfeedig practices i the developig world: Amog the mai causes of that declie [i breastfeedig rates] has bee the spread of artificial ifat milk whose maufacturers looked outward from the stagatig markets of the idustrialized coutries i the 1960s ad 70s ad saw the potetial of icreasig sales amog the large ad risig ifat populatios of the developig world. We eed to restart a campaig that reveals what formula compaies do. It s simple math: if they sell more formula, less wome breastfeed. We have to reveal that fact to the world come out i frot of the curtai ad be louder about it. (S19) Thirty years later, Grat s statemet souds like a prophet s warig. Baby food is a attractive idustry a $30 billio market that is growig 10% aually, says The Ecoomist magazie 91. A study i the Philippies foud Filipio mothers who had bee iflueced by advertisemets or their doctors to use ifat formula were two to four times more likely to feed their babies with those products. 92 Aother research group determied oe-third of Philippie families livig o less tha $2 per day purchase formula ad had substatially higher medical expeses compared with o-formula-buyig families. 93 The cocer expressed was global: These compaies are powerful to such a extet. Oe day I got a email sayig Nestlé ad Reault had a better-thaaverage week, ad this had boosted the whole of the EU ecoomy. These thigs matter to politicias right at the top i coutries havig crises how ca they make the ecoomy perform, how ca they get jobs. (S12) UNICEF 39

FIGURE 8 These are the words most used by stakeholders to describe the threat that formula compaies pose to breastfeedig practices also Chia stuff Nestles ecoomy GLOBAL breastfeed breastmilk differet UNIFIED thigfuture work supply baby s health Miistry parets powder ifatyearsfood eve positio aroud health successful substitutes Yeme expesive see STRATEGY woderful sustaiable powerful populatio must PREVENTING message atural whole political IQ commitmet People much goig icrease chage wat just providig problem sposorship oe compay violator history way coutry breastfeedig commuity LACK get go still far quite impact feedpeople issue private make actually Chile mothers buy promote year coversatioadvocacymilk baby better thik FACTORS ti right support day like eeds always strogidustry formula thigs workig dirty wome FUNDING Philippies guess happeig bradig wi INDUSTRY stakeholder water childre terms coutries importat reallyeed moitorig had huge feedig disasters expected completely preted ow well extremely global moths sayig wet improve week safely world developmetcompaies level sector kow claims Nestles Lobby pressure from ifat formula ad baby food maufacturig compaies is ever stregtheig ad spreadig rapidly i emergig markets. Political commitmet is essetial to strog, sustaiable global ad atioal advocacy for breastfeedig. (Q18) There is a huge eed to icrease political advocacy for breastfeedig i Yeme to mitigate the impact of malicious advocacy efforts of the formula compaies here. They are ifluecig the private health sector, which is providig health services to more tha 40% of the populatio. (Q14) Amog the 68 coutries that accout for over 95% of materal ad child deaths, oly 22 have adopted atioal legislatio coverig all provisios of the Iteratioal Code of Marketig of Breastmilk Substitutes 94. May respodets said much more advocacy ad political will is eeded to stregthe eforcemet of the Code, while ackowledgig the degree of ifluece wielded by the baby food idustry: My feelig is a formula compay caot follow the Code or they wo t make ay profit. I Zimbabwe a coutry I m workig o they re givig kickbacks to health workers to promote formula. It s happeig all over the world. (S4) The impact of regulatio o formula sales i Asia has bee oted by the idustry itself. From the Chia perspective where oly 28 percet of ifats uder-6 moths are exclusively breastfed Idia appears to be a model for strog Code implemetatio, as oe stakeholder observed: 40 BREASTFEEDING ON THE WORLDWIDE AGENDA

Obviously, battlig the formula compaies of the world is a huge problem i a coutry like Chia. Lookig at what Idia did tighteig up o breastmilk substitutes, puttig i tough legislatio ad takig people to court that would really make a differece. I ca t see that happeig i Chia i the immediate future. (S19) From the Idia poit of view, the battle is t wo yet: The test of legislatio i Idia has ot yet take place at scale because the vast majority of Idias are still livig below the poverty lie. Whe that chages, that will prove to what extet legislatio which is good o paper is eforced so optimal ifat feedig practices are protected. (S19) Allure Attractiveess of the issue to those who might wat to address it Leadership ad commitmet for a issue does ot oly stem from champios i the domai of orgaizatios, istitutios ad Govermets, but also champios who capture the public imagiatio ad attetio. May stakeholders cited the crucial importace of champios to promote breastfeedig practices, whether the audiece is global decisio makers or youg mothers ad their ifluecers. Respodets said champios who ca project charisma (S7) ad itimacy (S11) will be particularly effective. I the curret media eviromet, people wat to see celebrities. If Victoria Beckham breastfeeds her baby, it s much better tha Ba Ki-moo tellig people to breastfeed. (S16) Examples of global ifluecers i top tier circles iclude Melida Gates, Michelle Bachelet ad Has Roslig. Wome celebrities ca also play a importat role as role models who advace public debate: Whe you have Beyocé, the recordig artist, breastfeedig her baby i public, it caused all kids of stirs. That s exactly who you wat. 95 FIGURE 9 Milk formula retail value sales i Idia ad Chia 2002 2008 The huge disparity i the retail value of milk formula sales betwee Chia ad Idia is maily due to the sigificat differeces betwee their official regulatory regimes 4,000 3,500 3,000 US$ millio 2,500 2,000 1,500 1,000 500 0 2002 2003 2004 2005 2006 2007 2008 Source: Euromoitor Iteratioal, 2008 Chia Idia UNICEF 41

Coutry-based iterviewees metioed atioal ambassadors such actor Aamir Kha i Idia ad ad film artist Ma Yili, UNICEF Chia Special Advocate for Breastfeedig ad Early Childhod Developmet. They emphasized that First Ladies have bee very ifluetial, icludig First Lady Ai Bambag Yudhoyoo, Idoesia s Natioal Breastfeedig Spokeswoma 96. Wome persoalities have throw their weight behid both sides of the cotroversy, pittig those protectig breastfeedig from corporate marketig iflueces 97 versus those aliged with the baby food idustry 98. If breastfeedig stakeholders pursue the recommedatio to egage more champios ad celebrities, it is recommeded that a issue paper be developed to defie the reputatioal issues which this may raise, with a view to maagig them effectively. IDEAS Aother area where there is some lack of cosesus i the global policy commuity is evidece for the feasibility ad effectiveess of itervetios to improve breastfeedig practices. The evidece base exists ad results from a wide rage of coutries show that breastfeedig practices ca chage. However, this evidece may ot be uiversally kow or used, ad this may be the reaso why the stakeholder survey revealed a lack of agreemet. While the utritio commuity has coalesced aroud the shared framework of the Scalig Up Nutritio (SUN) movemet to scale up actio 99, stakeholders raised various cocers o key programme ad policy issues. These are the mai topics stakeholders cited as eedig more discussio ad cosesus: Iteral Frame Commo policy commuity uderstadig of problems ad solutios related to breastfeedig programmes Respodets shared differig perceptios regardig the stregth of the curret evidece base: FIGURE 10 Ma Yili with breastfeedig advocates from 15 Chiese cities gather for a workshop o the 10m2 of Love campaig. The campaig aims to locate, register, certify ad publicize breastfeedig rooms, both for employees i private compaies as well as for patros ad customers i public buildigs ad stores. 42 BREASTFEEDING ON THE WORLDWIDE AGENDA

FIGURE 11 25 coutries with icreases i exclusive breastfeedig i childre < 6mo of ~20 percetage poits i approx. 10-year period 100 90 80 70 60 50 40 30 20 10 0 39 39 40 32 32 33 34 37 26 27 12 11 16 12 3 1 4 3 74 76 71 60 61 63 54 55 52 48 48 50 43 43 44 46 44 39 29 24 20 10 11 10 11 6 7 16 18 19 10 12 Uzbekista (96; 06) Niger (98; 10) Sierra Leoe Keya (98; 08) Guyaa (00; 09) CAR (95; 06) Pakista (95; 06) Seegal (97; 05) Albaia (00; 06) Turkey (96; 08) Bei (96; 06) Colombia Swazilad Mauritaia Maldives (01) Guiea (99; 08) Tazaia (96) Lesotho (96; 09) Georgia (00; 11) Bolivia (00; 08) Zambia (96; 06) Togo (98; 10) Malawi (00; 10) Cambodia (00; 08) Sri Laka (00; 07) Circa 1998 Circa 2008 Source: UNICEF database for The State of the World s Childre 2012 Amog stakeholders, there appears to be two camps those who are coviced breastfeedig is importat ad practices ca be chaged, ad those who doubt the feasibility ad therefore dowplay its importace. The later camp will eed to be persuaded by evidece it ca be doe (Q4). There seems to be sufficiet kowledge of what eeds to be doe, based o the Lacet series ad Copehage Cosesus. There is a paucity of evidece o how to do it. (Q11) While some poited to the perceptio breastfeedig practices ca t be chaged, the data o breastfeedig clearly shows this is ot the case: 25 coutries have recorded gais of 20 percetage poits or more i exclusive breastfeedig rates i the past 5 10 years, accordig to UNICEF s database. I fact over 60 per cet of the 93 coutries with tred data betwee 1995 ad 2011 show a icreasig tred; ad some coutries have moved from a situatio of almost o exclusive breastfeedig to rates over 70 per cet. Evidece from these coutries fids success was liked to comprehesive programmatic approaches at scale, icludig these elemets: UNICEF 43

Policies guided by the WHO-UNICEF Global Strategy for Ifat ad Youg Child Feedig, icludig adoptio ad implemetatio of atioal legislatio o the Iteratioal Code of Marketig of Breast-milk Substitutes Materity protectio for workig wome Esurig breastfeedig is iitiated i materity facilities (ad o ifat formula is used) The stakeholder resposes o this issue highlight the eed for better sharig of evidece for effective breastfeedig itervetios, the wider dissemiatio of good practices i desigig, prioritizig ad plaig at-scale strategies ad also of failed or less successful efforts, ad the eed for policies that stick 101, to quote The Lacet 2008 Nutritio Series, meaig commitmet to more practical, simple ad tailored traslatio of policies ito actio. Buildig health-provider ad commuity worker capacity to offer couselig o ifat ad youg child feedig Trackig breastfeedig itervetios: how good is our measuremet? Mother-to-mother support groups i the commuity, accompaied by commuicatio strategies to promote breastfeedig, usig multiple chaels ad messages tailored to the local cotext. We eed to geerate evidece breastfeedig practices ca be improved at large scale withi a reasoable time frame, because that creates excitemet it ca be doe. You ca oly achieve scale if you simplify ad focus. (S19) Some Wester coutries such as Norway ad Swede have bee very successful i promotig the beefits of breast milk over bottle-feedig ad shiftig the social orm back to breastfeedig ad away from formula. Oe study showed 99 percet of mothers ursed their ewbors i the hospital. Six moths later, 80 percet were still ursig, compared with 20 percet i Britai ad 32 percet i the Uited States 100. May respodets said ew research is urgetly eeded to determie the optimum bled of face-to-face couselig, group commuicatio ad remote messagig, desiged to raise breastfeedig rates i a ecoomical maer. They are also lookig for clear strategies to effectively chage social orms. (Q11) Several said programmes must be embedded withi atioal health systems if they are to be sustaied: I Madagascar, the rate of exclusive breastfeedig icreased quite dramatically at the atioal level whe all agecies were egaged, but after the project obody followed up. The followig survey showed rates fell to what they were earlier. Breastfeedig has t bee part of ay system it s probably why it s collapsig. (S7) Commitmet to the measuremet of breastfeedig practices is firmly embedded i the major household surveys which assess health ad utritio, icludig the Demographic ad Health Survey ad the Multiple Idicator Cluster Survey. However, efforts to measure the scope, scale ad coverage of breastfeedig itervetios have ot bee stadardized or uiversally applied i all developig coutries, ad eve where udertake, they reveal a far from optimal scope of breastfeedig programmes ad fail to capture the scale or coverage 102, 103. This may be oe of the factors cotributig to the low tractio ad resourcig for breastfeedig programmes: o oe isists o accoutability for coverage of the breastfeedig itervetios o the same aual basis as for example immuizatio coverage or coverage with the treatmet of severe acute malutritio. A 2011 Pediatrics article oted few childre i the developig world beefit from optimal breastfeedig ad complemetary feedig practices. The authors suggest low coverage may be attributable to cultural beliefs, poor quality of couselig ad lack of a supportive eviromet. But they add it may also result from the gap betwee the idetificatio of core itervetios (what to do) ad a set of easy-to-use tools that show how the itervetios ca be effectively implemeted 104. As oe of the article s authors said: We kow about vitami A supplemetatio. We kow about iro supplemetatio. But do we kow whether mothers are couseled, which is ecessary for improvig feedig practices? Do we kow aythig about the quality of that couselig? Suddely we realize there is o data about that. (S1) 44 BREASTFEEDING ON THE WORLDWIDE AGENDA

Strog disagreemets o private sector egagemet stood out i the stakeholder survey Academic ad WHO respodets flagged the vital eed for better data collectio o the causes of poor feedig practices ad coverage of the utritio itervetios recommeded i The Lacet. A academic stakeholder added: We eed a uified strategy that has clear itervetios, evidece-based itervetios that lead to icreases i exclusive breastfeedig. Oce we have that, those itervetios are what we eed to track, because that will drive it. (S13) This respodet suggested that the Coutdow to 2015 data iitiative 105 should t oly be trackig wome s breastfeedig behaviour, but rather the itervetios to support it ad holdig people accoutable for doig that. (S13) Clearly, this requires further discussio regardig data collectio at the coutry level. What gets moitored gets prioritized, said aother iterviewee. (S16) Cohesio o solutios ca we develop a commo ageda o private sector egagemet? The strog disagreemets o private sector egagemet stood out i the stakeholder survey (see fidigs 1 Actors, policy commuity cohesio). The degree to which breastfeedig stakeholders ca reach a commo uderstadig o private sector egagemet directly impacts their ability to develop a public positioig of their issue that resoates with decisio makers. Ideology is distractig us from comig together to address the problem of breastfeedig with commo purpose ad a uderstadig of each other s stregths. (S15) Stakeholders were uited i recogizig the threat to breastfeedig, though variously egaged i direct actio to protect it. They diverged however over whether or ot to collaborate with private sector compaies to improve complemetary feedig. Some civil society respodets wared about coflicts of iterest. Aother said multiatioal food corporatios are jeopardizig family feedig practices, as well as budgets, i may poor commuities: We work closely with movemets o the right to adequate food, health ad utritio. It s ot oly food security, but also the sovereig ature of people ot beig always depedet o global markets, their whims ad prices. This is about ot havig to sped moey you do t have for Little Gerber jars, but ad beig able to make complemetary food for the baby at home. (S11) Respodets workig with private sector parters, o the other had, felt strogly about the eed to egage them as stakeholders: The utritio commuity eeds to figure out how to work effectively with the private sector o all aspects of itegrated utritio, because they are ot goig away. They have tremedous potetial to address some of the obstacles to improved utritio. Let s figure out how to do that. (S2) Others said there s a eed to focus more o the demad side creatig a market for better utritio. (S10) It s about uderstadig people are icreasigly usig the cash ecoomy. It s that culture of markets that s drivig a lot of behavior, ad we re ot haressig that well. It s more about egagig with people as cosumers ad uderstadig what motivates their behavior at that level. We ca lear a lot from busiess i desigig programmes. (S15) Some respodets called for a more creative approach: There are differet ways of collaboratig [with the private sector]. Ca they do hygiee promotio so breastfeedig ad ifat feedig could be executed i a cleaer eviromet? How about access to soap? How about creatig ways for mothers to reach health facilities o time to receive iformatio? Maybe we re oly lookig at the food compoet, ad ot seeig the whole eviromet i which breastfeedig becomes optimal. (S16) Clearly more dialogue is eeded withi the IYCF commuity to arrive at a shared positio o private sector egagemet. Some respodets, otably UNICEF staff, pleaded for big picture thikig o this issue: Formula ad ifat feedig compaies will grow bigger all over the world. We have a major role to play, egagig with UNICEF 45

The breastfeedig commuity must do a better job of redefiig its message ad tellig its story govermets so strog policies ad laws are eforced. We must also brig the private sector o board, lettig them kow that ot abidig by laws i the coutry is ot a optio. This is why those who care about ifat ad youg child feedig eed to be together. We caot afford disjoited messagig or disagreemet. We eed to focus o the bigger picture. (S18) Exteral Frame Public positioig of breastfeedig programmes that ispires exteral audieces to act The survey posed the questio whether stakeholders thought a advocacy strategy would be more effective if it were focused solely o mobilizig support ad resources for breastfeedig (a vertical approach) versus icludig breastfeedigwithi a itegrated package of itervetios. Stakeholders had two messages: 1. Breastfeedig advocacy must be itegrated ito the utritio ageda, icludig messagig o the 1,000 Days widow of opportuity xxxiii, as well as the child survival ageda. 2. There ow is a simultaeous eed for vertical advocacy to address low levels of breastfeedig i may coutries, ad promote it as the social orm ad preferred feedig optio for mother ad child. Several respodets defied this as the diagoal approach a coceptual model for global health goverace ad service delivery that embeds disease-specific iitiatives withi broader health systems 106. I would recommed a diagoal approach, either vertical or horizotal, where breastfeedig is preseted as a key buildig block of feedig i the first two years of life ad supportig mothers who do so. It should be very strog, evidece-based, aspiratioal advocacy. (S19) For breastfeedig stakeholders, this meas defiig the cotours of a vertical advocacy drive, ad itegratig it ito the frameworks of the SUN, the 1,000 Days, A Promise Reewed ad related iitiatives. Oe respodet described this as electrifyig key elemets of breastfeedig withi a itegrated approach, so it is t forgotte. (S6) A civil society respodet cautioed that itegrated plas should ot divert resources away from breastfeedig. (Q5) Aother stakeholder summarized it this way: If we ca take advatage of the widow of opportuity ad a driver to push the process, a vertical approach could help to geerate the learig, evidece ad excitemet eeded to sustai fudig log eough to demostrate programmes ca regularly be take to scale. (Q4) We eed to recast the arrative aroud breastfeedig. It takes creative people willig to thik outside the box ad ot be dogmatic. It s a ice story that ca be told very well, but there eeds to be support ad people willig to say: this is importat. (S3) May stakeholders were ethusiastic about the issue attetio which utritio is ow receivig at the global level. They oted that the 1,000 day widow of opportuity ad stutig reductio messages have already gaied political buy i from decisio makers at the highest level. They added however that breastfeedig has ot beefited from the same attetio. UNICEF media moitorig substatiates stakeholders perceptio that utritio is risig o the global ageda while breastfeedig remais largely ivisible. A review of UNICEF media coverage reveals that 13 percet of media stories focused o uderutritio, while breastfeedig s share remaied at 2 percet. Issue ascedacy for breastfeedig is tied to icreased media visibility Media coverage is a useful proxy idicator for issue visibility, sice policy decisios are t made i a vacuum. The media plays a importat role i iformig ad ifluecig decisiomakig ad public debate 107. Researchers who studied the topic of media visibility for global health priorities proposed a cyclical relatioship betwee global attetio, icreased fudig, ew iitiatives ad media coverage. Respodets ackowledged the breastfeedig commuity must do a better job of redefiig its message ad tellig its story. Buildig o the 1,000 days message platform, it must develop a resoatig frame for breastfeedig that ca geerate xxxiii 1,000 Days Iitiative, http://www.thousaddays.org/ 46 BREASTFEEDING ON THE WORLDWIDE AGENDA

FIGURE 12 UNICEF media coverage cofirms uderutritio is risig o the global ageda, but breastfeedig is much less visible Leadig child survival topics: share of traditioal media coverage Jauary 2010 May 2012 Share of Coverage Favorability Ratig 14% 12% 10% 8% 6% 4% 2% 0% 73 72 71 72 70 73 70 72 73 70 80 75 70 65 60 55 50 45 40 35 30 25 20 Uderutritio Hygiee / Saitatio Immuizatio Materal Health Polio Diarrhea Cholera Malaria Measles Breastfeedig Share of Coverage Favorability Ratig Source: CARMA Iteratioal, Global Media Aalysts buy i from govermet leaders ad other ifluetials. To do so, the commuity ca lear from media research. Too ofte, the story o breastfeedig is arrowly framed aroud the mother ad child. Framig literature tells us that uless we explicitly chage the picture, it will be hard for audieces to see why policy matters. Advocates should look beyod the portrait of the idividual mother ad describe the social ad cultural factors that make it difficult or udesirable to breastfeed 108. Advocates will have to agree o their priority issues, as well as o the laguage they use: Orgaizatios eed to stop just cosiderig breastfeedig. It s ot that wome do t breastfeed ad do othig. They ll do somethig else, ad we eed to address what the somethig else is. There s defiitely a reluctace to talk about formula feedig. I thik that s a huge problem. (S9) UNICEF 47

FIGURE 13 A compellig commuicatio strategy ca cotribute to a virtuous circle of media visibility, public attetio, further fudig ad ew iitiatives GLOBAL ATTENTION INCREASED FUNDING MEDIA COVERAGE NEW INITIATIVES Source: Hudacek D et al. Aalyzig Media Coverage of the Global Fud Diseases Compared with Lower Fuded Diseases. PLOS Oe. Policy makers perceptios must be addressed Wome respodets i particular said it was sometimes difficult to get decisio makers to uderstad what the problem is i relatio to improvig breastfeedig practices: Global leaders do t ted to thik about it because they ted to be me. The visual image of wome i poor coutries breastfeedig lead people to thik it s beig doe. They do t realize we re talkig about specific optimal breastfeedig behaviors, which are ot beig doe. So they thik: I m ot goig to worry about a buch of wome breastfeedig. (S6) Aother iterviewee added: Probably optimal practices are ot very clear i the mids of policy makers. Eve with doors, there is a lack of uderstadig of what it is. (S7) A updated advocacy case for breastfeedig eeds to address these perceptios, ad explore metaphors ad o-techical laguage which resoates with decisio makers: Nothig was more powerful for Bill Gates tha to be told by a woma i Idia that breastmilk was her baby s first immuizatio. He said, Okay, I m a vaccie guy, ad that s your first immuizatio. That captivated him. (S3) 48 BREASTFEEDING ON THE WORLDWIDE AGENDA

The curret level of stated political priority to reduce child stutig is uprecedeted POLITICAL CONTEXTS Momets i time whe coditios alig favorably for a issue The curret political cotexts at global, atioal ad local levels ifluece which issues gai attetio ad represet opportuities for advocacy. Nutritio has rise expoetially o the global ageda ad o atioal agedas i may coutries i the last few years. This opportuity must be capitalized o with urgecy for the proposed diagoal approach to advocacy for breastfeedig. Coutry agedas are heavily iflueced by global actio, or lack of it. If there is global attetio, there is a push for accoutability ad the issue gets more attetio. This has t bee the case for breastfeedig i recet years. (S16) Policy widows ad advocacy opportuities Issues log eglected ca retur to ceter stage with the right combiatio of leadership, timig, resources ad civil society mobilizatio. The curret level of stated political priority to reduce child stutig is uprecedeted at the global level, icludig a 2012 G-8 commitmet to a New Alliace for Food Security ad Nutritio 109. Leaders of high burde coutries such as Idia are also sigalig a ew resolve to address the problem with a high level, iter-sectoral respose 110. Stakeholders ackowledged the curret widow of political attetio must ot be missed, ad recommeded follow up actio via the SUN public-private partership i particular. They suggested the SUN platform be used to repositio breastfeedig as the corerstoe for improvig materal ad child utritio durig the 1,000 days (Q16) ad cetral itervetio that achors everythig else. (S6) Civil society respodets geerally cocurred, while flaggig the risk of coflict of iterest for private sector actors. They called o the SUN to put a strog policy i place to guard agaist this, sayig: You could have formula compaies beig FIGURE 14 Stakeholders agreed the rise of utritio o the global developmet ageda is a ecouragig tred, icludig icreased awareess by govermet leaders of coutries with large umbers of o-exclusively breastfed childre such as Idia MAIL TODAY BUREAU MAIL TODAY NEW DELHI, JANUARY 11, 2012 UPDATED 14:30 IST Malutritio is a atioal shame, says Prime Miister Mamoha Sigh TAGS: Malutritio Prime Miister Mamoha Sigh Amartya Se Itegrated Child Developmet Scheme Prime Miister Mamoha Sigh has called malourishmet amog childre a atioal shame. Source: Scree grab, INDIATODAY.i UNICEF 49

part of SUN before you kow it! (S11). Sice the survey was coducted, oe of the civil society stakeholders has take the positio that i view of the cocers about the role of busiess i SUN, IBFAN ad may of its allies caot support the SUN iitiative 111. The SUN cosultatio process should be coducted i close liaiso with its Coordiator, ad be iclusive of civil society advocates. I developig the updated advocacy case, stakeholders should build wherever possible from the wealth of existig resources. Several UNICEF coutry represetatives said the SUN ageda must be itegrated ito existig coutry programmes to have sustaiable impact. A couple of case studies are preseted to illustrate coutry efforts ad approaches i this regard. The Tazaia coutry office credited high-level political attetio via the SUN as a major catalyst for govermet commitmet to tackle uderutritio through itegrated approaches (see box) Coutry data ca provide a powerful advocacy opportuity. Stutig reductio is both a idicator ad frame that resoates with Miisters of Fiace, sice it commuicates the loss of idividual ad atioal potetial. Coutry utritio data ca provide a powerful advocacy opportuity (see Advocacy Case ADVOCACY CASE STUDY: A high-level Tazaia visit shies SUN light o ifat ad youg child feedig Tazaia has made strikig progress i may health idicators over the past decade, but ot utritioal status. Stutig curretly affects 42 percet of uder-five childre, with Tazaia s stutig burde the third highest i Sub- Sahara Africa, after Ethiopia ad the Democratic Republic of Cogo. Half of Tazaia ifats aged less tha 6 moths are exclusively breastfed. Youg ifats are ofte give water, juices, porridge ad other foods, which family members ad peers ofte ecourage, ot realizig they edager the utritioal status ad health of ifats. The biggest problem was breakig through a lack of acceptace at the top level about the importace of utritio, said UNICEF Tazaia respodets. Govermet ad developmet parters had drafted a atioal utritio strategy, but it took a high-level visit i Jue 2011 by US Secretary of State Hillary Clito ad Irelad s Deputy Prime Miister to catalyze a political breakthrough. It was durig their stay that Tazaia siged up to the global SUN movemet as oe of the early riser coutries, with Presidet Kikwete later acceptig a ivitatio to joi the SUN Lead Group. The govermet was ready to move forward, but that provided the push to make it happe, said UNICEF respodets. Tazaia s Prime Miister aouced six major commitmets for utritio at the time, all of which have ow bee met or see sigificat progress. UNICEF Tazaia praised the govermet s itegrated approach: It s ot just a matter of promotig breastfeedig. The issue must be looked at i a comprehesive maer, icludig actios to address the challeges wome face to feed ad care for their youg childre, such as their high workload. UNICEF is workig with local govermet authorities to ehace their leadership ad maagemet skills for improved utritio, ad supportig parliametarias ad a civil society-led partership icludig idigeous NGOs ad faith-based orgaizatios coverig most of the coutry. Source: UNICEF Tazaia 50 BREASTFEEDING ON THE WORLDWIDE AGENDA

New champios are eeded to esure political promises are trasformed ito geuie actio Supportig wome to breastfeed must be a prioritized across the Africa cotiet. A woma breastfeeds her baby uder a mosquito et, i the village of Gari Badjii, i Niger. Her village has beefited from sessios raisig awareess of essetial family practices, icludig exclusive breastfeedig. Study o Vietam). Stutig reductio is both a idicator ad frame that resoates with Miisters of Fiace, sice it commuicates the loss of idividual ad atioal potetial. The SUN movemet is ot the oly major opportuity for breastfeedig advocacy a umber of global health iitiatives also afford importat opportuities to itegrate efforts to ehace political commitmet to breastfeedig. Accoutability for breastfeedig should be shared by health ad utritio, requirig a itegrated advocacy approach ad strategy. To be successful, advocacy at all levels must be itegrated across both sectors. May respodets highlighted the eed for this itegratio, icludig this plea from a Africa-based respodet: The oe thig I hope would ot happe is a special ew iitiative o breastfeedig because we ca t keep up! We get a ew iitiative every week. Rather, it s placig breastfeedig withi the framework of the thousad iitiatives already uderway! (S23) Stakeholders said the first priority is to egage the reproductive, materal, ewbor ad child health commuities who have coalesced aroud the UN Secretary Geeral s Every Wome, Every Child global effort xxxiv, A Promise Reewed xxxv, Savig Newbor Lives 112, the Partership for Materal, Newbor ad Child Health 113 ad the Coutdow to 2015 trackig iitiative 114. New champios are eeded to esure political promises are trasformed ito geuie actio said may iterviewees, ad breastfeedig advocates eed to be more strategic i idetifyig xxxiv Every Woma, Every Child, http://www.everywomaeverychild.org/ xxxv A Promise Reewed, http://www.apromisereewed.org// UNICEF 51

A ew social movemet is eeded to re-establish a culture of breastfeedig ADVOCACY CASE STUDY: Drawig ifluece maps to protect wome s right to breastfeed i Viet Nam Viet Nam takes egative data about its developmet very seriously, said UNICEF Represetative Lotta Sylwader. They do t like the fact that 30 35% of the coutry s childre are still stuted, so they wat to do somethig about it. It was fidigs from a atioal Nutritio Survey that provided UNICEF ad the Alive ad Thrive iitiative with the ammuitio they eeded for a major advocacy drive o breastfeedig. Whe the survey was published, it was a big blow beig a lower middle-icome coutry ad still havig oe third of your child populatio beig stuted. Breastfeedig rates had plummeted i Viet Nam as i other East Asia coutries where ifat formula is aggressively marketed. A Alive ad Thrive survey also revealed pressure to retur to work was forcig Vietamese wome to abado exclusive breastfeedig. Armed with these fidigs, the two orgaizatios wet to the Natioal Assembly ad worked with its Ceter for Legislative Studies to craft strog laws addressig both issues. Alive ad Thrive ad UNICEF supported preparatio of high quality policy briefs makig the case to parliametarias. They also worked with the Assembly to take the debate about youg child feedig ad breastfeedig to the regioal ad local levels, supported by Alive ad Thrive s provicial staff. Both parters focused sigificat eergy o idetifyig those key idividuals who could make the case to high-level decisio makers i govermet ad the legislature. We are costatly drawig a ifluece map, said Sylwader. Their efforts paid off: i Jue 2012, Viet Nam s Natioal Assembly passed the Law o Advertisemet which icludes a ba o the marketig of breastmilk substitutes for childre uder 24 moths. Parliametarias also passed a Labour Code revisio by a wide margi, allowig the extesio of materity leave from four to six moths. Now the focus is o esurig the ew legislatio is put ito practice ad promotig behaviour chage via oe-o-oe, telephoe ad group couselig, supported by a sophisticated media campaig positioig breastfeedig as the clear choice for the moder Vietamese wome. the right players i the game ot always the most obvious. (S19) Suggestios iclude a UN Special Evoy for Ifat ad Youg Child Feedig (S16) ad a IYCF czar i coutry, who has the direct support of the Health Miister. (S8) Nurturig a social movemet for breastfeedig Social movemets ca be importat for fosterig broad, popular ivolvemet, owership ad commitmet to a cause or issue, with participatio from a wide rage of stakeholders. Such a movemet could help to brig about the social chages ad shifts i values amog all costituecies, from families ad grassroots orgaizatios to govermets, doors ad compaies, that are eeded for breastfeedig s star to rise. Some of the survey participats said a ew social movemet is eeded to re-establish a culture of breastfeedig, to be developed i partership with related costituecies. To grow a social movemet, lear from other advocates. The WASH programme has gaied valuable experiece, for example, o WASH i schools, hadwashig with soap ad shiftig social orms o ope defecatio. Amog their lessos leared: 115 focus o wat, eed, desire for behaviour to chage, experieces have to be radical, real, immediate ad dramatic 52 BREASTFEEDING ON THE WORLDWIDE AGENDA

whe frames of mid chage, behaviour chage is easy for behaviour chage, social orms must chage. A breastfeedig stakeholder i West Africa gave this example: I the orth of Ivory Coast, which has very low exclusive breastfeedig, we had oe village where almost all mothers are breastfeedig exclusively. The the other villages are iterested ad they wat to be part of the movemet. So, there s kid of a buzz. It takes time though. It s ot goig to be a magic bullet. That is what we eed to uderstad. (S23) Others spoke about the eed to reach out to groups workig for cosumer educatio ad sustaiable developmet: What we do t have right ow is a focus o the importace of creatig a movemet amog cosumers to have better literacy aroud utritio, so they demad better products ad services from govermets. Markets are drivig a lot of behavior, ad we re ot haressig that well. (S15) From Idia home to the largest umber of stuted childre 116 came this perspective: What s emergig i Idia is that the largest iequities are related to complemetary feedig practices, whereas breastfeedig idicators are less iequitable. That is tellig us exclusive breastfeedig will be see as somethig for the poor. If our advocacy is ot able to preset exclusive breastfeedig as somethig the elite aspire to, we will see decliig rates, because Idia is chagig. It s a ew time, ad our advocacy eeds to be ew. (S17) Aother podered: How do we make breastfeedig ad utritio aspiratioal to mothers, families, commuities, policy makers ad public opiio at large? How do we lik optimal breastfeedig practices to brai developmet, school performace ad success i life? If we hit that oe, all the rest legislatio, moitorig the private sector ad so forth will come ito lie. (S18) UNICEF 53

DISCUSSION It is ackowledged that breastfeedig practices ad patters are determied by a large array of cotext-specific factors, oly some of which are ameable to ifluece ad chage by a global policy commuity. Some of these factors, refereced by the stakeholders, iclude ecoomic developmet patters that put more ad more wome ito the workforce (but without supportig mechaisms for optimal ifat feedig), social chages such as urbaizatio that also alter wome s lives (which this commuity caot ifluece), the diffusio of orms surroudig breastfeedig (which this commuity may have some ifluece o but there are may other determiats of this, ad has more to do with cotext-specific programmatic itervetios for social ad behavior chage), ad food idustry efforts to peetrate ifat feedig markets (which this commuity ca shape to some extet but also are determied by may other factors). The aalysis focuses o the cotributio a global commuity of advocates might make to improvig breastfeedig patters amidst this causal complexity, ad particularly i ifluecig oe aspect of the causal picture: global political attetio ad leadership. Thus the aalysis ad recommedatios do ot aim to address techical ad programmatic issues, icludig commuicatio to the public o social ad behavior chage. O some aspects of the survey, the stakeholder resposes sometimes veered ito issues ot related to global political commitmet ad advocacy, perhaps reflectig their programmatic ad coutry focus or perhaps their partial uderstadig of the meaig or boudaries of the domai of political commitmet ad advocacy. We have therefore omitted from the fidigs some of these poits that do ot directly reflect the goals ad focus of the aalysis. 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 coutries, 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. 54 BREASTFEEDING ON THE WORLDWIDE AGENDA

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 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 marketig of breastmilk substitutes, 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. While most coutries collect data o may of the stadard IYCF practice idicators through atioal household surveys, a major gap that was idetified is the lack of stadard frameworks ad systems to moitor the performace ad coverage of IYCF itervetios. Global cosesus o a harmoized ad comprehesive set of idicators to measure the performace of IYCF programmes ad itervetios, icludig geographic ad populatio coverage, is eeded. Accoutability to report o their status should cotribute towards icreasig the commitmet ad priority for breastfeedig ad complemetary feedig. It will therefore be crucial to advocate for the moitorig frameworks of coutry strategies ad atioal iformatio systems to be updated to iclude this set of idicators. The ladscape sca highlighted ad reaffirmed a umber of issues ad factors that have bee hamperig progress: isufficiet global leadership ad guidig istitutios low prioritizatio ad fiacial commitmet by doors ad policy makers of IYCF ad growig polarizatio over support to breastfeedig vs complemetary feedig istead of a comprehesive approach to improve both lack of advocacy ad commuicatio with compellig, up-to-date iformatio ad effective approaches. Shiffma s aalysis of the materal health commuity 117 idetified four challeges advocates eeded to overcome to advace their cause: solidify policy cohesio, so the commuity speaks with authority ad a uified voice; create edurig guidig istitutios to sustai the iitiative; fid exteral frames that resoate with political leaders, ad build strog liks with civil society orgaizatios ad iitiatives at the coutry level. Those challeges ad questios are the same oes raised by breastfeedig stakeholders: We have guidig istitutios. Will they lead? We kow breastfeedig stakeholders are polarized over key issues. Are they willig ad able to fid commo groud? We have atioal civil society ad NGO advocacy iitiatives. Ca we stregthe their roles ad uify their voices? We ve created a resoatig frame for the 1,000 days. Ca we do the same to recast the arrative o breastfeedig for the 21st cetury ad make a aspiratioal case that resoates with all the costituecies who eed to come o board to achieve the visio of improvig breastfeedig practices? Ad last but ot least: ca we fid the resources we eed to advace this process? The aswers to these questios will determie the future success of breastfeedig advocates to realize their exceptioal potetial to save lives ad promote healthy developmet. Advocates ow have the best political opportuity i a geeratio to advace their cause if they are ready to capitalize o it. lack of policy commuity cosesus ad uity, with egative attetio ad fraught discussios, rather tha pro-active prioritizatio ad egagemet ucertaities o private sector collaboratio i the area To do so, breastfeedig stakeholders must be willig to make a big leap forward: come together as a cohesive advocacy commuity grouded i a commo ageda, with shared measuremet ad mutually reiforcig activities. UNICEF 55

I the past few years, utritio advocates have made remarkable strides to secure commitmets at the highest levels of govermet for global ad atioal ivestmet i the 1,000 days widow of opportuity. Stakeholders cosulted for this study called for a diagoal approach to breastfeedig advocacy to reaffirm its multi-faceted cotributio. They proposed a vertical advocacy iitiative for breastfeedig withi the 1,000 days ad SUN cotext. Realizig a ew visio for breastfeedig advocacy will take courage, creativity, perseverace ad flexibility. It will require each idividual ad stakeholder orgaizatio to come together with fresh purpose to trasced policy disagreemets that have costraied commo actio i the past. Those who have gaied the most from the commuity s dissoace are shareholders of baby food compaies. Those affected most detrimetally are wome ad families strugglig to give their ifats the best start i life. 56 BREASTFEEDING ON THE WORLDWIDE AGENDA

A sigificat scalig up of cotiuous advocacy is eeded to icrease attetio ad commitmet THE WAY FORWARD 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. A global iitiative to address these issues is urgetly eeded, with a clear focus o global advocacy, leadership, mobilizatio of commitmet, rather tha techical or programmatic issues. The proposed iitiative should aim to help esure that i a rapidly chagig world, all childre everywhere beefit from optimal ifat ad youg child feedig practices both for their survival, growth ad developmet i childhood ad for log term outcomes i adulthood. The followig proposals build o stakeholder feedback from the survey, as well as the outcomes of the small stakeholder cosultatio held i February 2013 to review the fidigs of the ladscape aalysis ad cotribute to articulatig cocrete proposals for the way forward. The ultimate goal of the five recommeded actios is: To galvaize actio for the protectio, promotio ad support of optimal breastfeedig ad complemetary feedig i the 21st cetury, i pursuit of accelerated improvemet of the ifat ad youg child feedig idicators for all childre everywhere. 1. Recast the arrative: Defie a shared advocacy ad commuicatio visio ad ageda for breastfeedig ad complemetary feedig, reframig the arrative for the 21st cetury. This is the opportuity for a coalitio of the willig to joi forces to craft a commo visio, strategy ad tools to support global, regioal ad coutry evidece-based advocacy for breastfeedig ad the 1,000 days. Recastig or reframig the arrative o optimal ifat ad youg child feedig implies creatig ad effectively deployig the right arrative for the right people at the right time. A commo global advocacy ad commuicatio ageda should defie key audieces, measurable goals, idicators for measurig progress ad mutually reiforcig activities. The ageda should cofirm how each parter will cotribute, based o their expertise ad potetial to add value. New messages, tailored to audiece, cotext ad to what resoates ad motivates differet stakeholders, are eeded for coutry leadership ad opiio shapers, doors, agecies ad the public. More of the same will ot produce results. The case for optimal IYCF has to be aspiratioal for all the differet stakeholders. I developig the advocacy ageda, it will be importat to cosider the stakeholder iputs regardig the barriers wome face to breastfeed i a 21st cetury world ad policy actio to create a more supportive eviromet. Asia-based stakeholders called for ew resources makig the advocacy case for breastfeedig i emergig ecoomies where child mortality has declied, ad govermet leaders are focused o developig huma capital ad competitiveess. UNICEF 57

Issue fatigue o breastfeedig eeds to be overcome ad the debate eeds to be re-eergized. 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. The aim is to brig about a shift from the curret toke reflectio that breastfeedig ofte receives i movemets, orgaizatios ad coutries, towards o-egotiable commitmet to at-scale ad comprehesive delivery of the itervetios to improve practices at the heart of policies ad programmes for child survival ad utritio. This essetial area of actio requires multiple agecies workig i a coordiated maer. It requires professioal support from experts o commuicatio, marketig ad advocacy. This is crucial to the recastig process, which must etail a shift from previous paradigms ad approaches which have ot yielded the iteded results i terms of political priority ad commitmet. The recastig process also ivolves a skill set related to review of the scietific literature o all aspects of the beefits of optimal feedig the effectiveess of itervetios to provide correct ad succict iformatio to the advocacy ad marketig specialists. The advocacy iitiative will require a strategy, materials, messages ad tools addressig the various stakeholders ad evets. These may iclude the developmet of a detailed advocacy strategy ad toolkit for coutries ad stakeholders. This will ivolve both a summary of scietific evidece o all impacts of IYCF (survival, utritio, learig, ecoomic argumets, developmet, NCDs/obesity) ad a commuicatio/advocacy piece o how to frame ad recast the message, which must be fresh ad differet from previous messagig. Differet messages/hooks will be eeded for differet audieces. FIGURE 15 These are some of the words stakeholders used to describe the focus ad toe for future breastfeedig advocacy iitiatives ew school bright success egage excitemet evidece hard-hittig wome-focused social cotemporary celebrities creative aspiratioal cosumer itelligece 58 BREASTFEEDING ON THE WORLDWIDE AGENDA

2. Advocate ad ifluece: 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 SUN ad APR, ad at the same time some specific vertical advocacy o breastfeedig. This will requires a strategic, creative, iovative ad forward-lookig craftig of the advocacy approach. A shared IYCF ageda eeds to be itegrated ito existig global advocacy iitiatives for utritio ad materal, ewbor ad child health. While advocacy for IYCF ad breastfeedig have a atural home uder the SUN umbrella, they must also be fully itegrated withi major advocacy iitiatives for health, otably A Promise Reewed, ad i other related sectors, ad also withi the frameworks for emergecy resposes. Liks with the icreasigly promiet utritio-sesitive agriculture ad social protectio iitiatives also eed to be explored. Differet groups to be addressed iclude leadership of coutries, door ad agecy leadership, parterships, potetial champios, the media ad public opiio. Evets ad opportuities for advocacy ad ifluecig eed to be idetified. Coordiated advocacy plas eed to be developed ad executed, deployed i appropriate global fora, at high level i coutries ad through relevat chaels to the public. A particular aim is to motivate politicias, policy makers, doors ad others that results for IYCF are desirable ad possible i relatively short time. They eed to be provided with tools ad support so they, ad others, ca become ambassadors for this cause. A importat aspect is stregtheig the ivestmet case for breastfeedig, buildig o research coducted by the World Bak, UNICEF, Save the Childre ad IBFAN highlightig its beefits, cost savigs for govermets, ad costs of deliverig a package of effective itervetios. The ivestmet casig eeds to bled the data-based case with a aspiratioal message promotig the 1,000 days as a smart ivestmet with big returs. These fidigs eed to be itegrated ito existig ivestmet cases for utritio ad materal, ewbor ad child health. Take this case to govermet leaders ad decisio-makers at all levels, icludig policy dialogues ad practical guidace regardig idicators to moitor the effectiveess of programmes ad the outcomes of the ivestmet. Media both ew ad traditioal ca play a powerful role to raise awareess amog the public i door ad programme coutries ad policy makers alike, regardig the beefits of breastfeedig ad ofte-ivisible costs of formula ad mixed feedig. It will be importat to sca the developmet ad social media ladscape to idetify opportuities for itegratig breastfeedig messages ad lessos leared from early adopters. A social media strategy to itegrate breastfeedig protectio, promotio ad support ito parter commuicatio outreach eeds to be developed. Global ad atioal champios could be elisted to promote the message, both celebrities ad high-level persoalities. Promiet persoalities ad celebrities at global ad atioal levels could be elisted, especially but ot oly wome, to covey the message as part of a aspiratioal advocacy ad commuicatio campaig to positio breastfeedig as the feedig choice of the moder mother i the North ad South. Also critical is urturig a social movemet repositioig breastfeedig as the optimum feedig choice for the moder woma ad child, which civil society orgaizatios ad NGOs should be supported to do i a positive ad proactive way, applyig best practices from social chage campaigs, cosumer educatio ad private marketig, otably via commuity buildig olie. To icrease impact, dialogue ad itegrated advocacy with related costituecies should be developed, such as those advocatig for materal, ewbor ad child health, early childhood, WASH, HIV prevetio ad treatmet, geder equality, girls educatio ad youth egagemet. 3. Esure a uified voice: The lack of cohesio ad uity amog the global policy commuity stood out i the stakeholder aalysis. The utritio ad child survival advocacy commuities will have most impact whe they speak with oe voice. NGO ad civil society parters i particular should work towards a uified positio o the role of the private sector i advacig IYCF goals. UNICEF 59

This area of the ageda ivolves global coordiatio to esure a uified voice ad cosesus o goals ad strategies, recogizig that cohesio ad cosesus are vital o the mai priorities ad issues ad also recogizig that ot everyoe will always agree with everythig. It should ceter o creatig a safe space for policy dialogue where outstadig issues of disagreemet ca be debated costructively ad the best iterests of the child placed at the ceter so all actors ca rally together. Establishig a global coalitio may play a importat role to play i addressig misiformatio ad esurig that the divergig views are better maaged to shift the arrative to a more positive space ad reduce the curret high level of egativity that threates to derail the ageda. 4. Provide strog leadership for cohesive actio ad results: Stakeholders called for strog leadership ad guidig istitutios to advace the ageda. This area of actio ivolves assumig a leadership fuctio ad backboe support to pursue the global, uified advocacy ad leadership iitiative o IYCF. This will iclude amogst other thigs the developmet ad executio of a strategy ad pla related to this ageda, coordiatig the developmet of advocacy messages ad materials, pursuig opportuities for advocacy, ad spearheadig the process of reachig areas of cosesus i the global commuity of stakeholders. Actios for the leadership body may also iclude coveig evets, cosultatios ad meetigs. Possibilities to shape a global coalitio to advace the ageda should be explored. A coalitio, which does ot ecessarily eed to be a Partership or a separate etity, should be characterized by its impartiality, professioalism, trust ad respect, ad could brig more impetus, stregth ad uity. It should serve as a bridge to multiple agedas, urturig partership ad liks with SUN, APR ad other fora, aimig to serve the goals of these parterships ad fill gaps. The coalitio eeds to be bold, up frot ad iovative i makig the case for IYCF: it will eed to thik big. It should also have clear tagible goals, deliverables ad plas that cotai the key elemets uderpiig its purpose. 5. Mobilize resources, actio ad accoutability: Stakeholders cosistetly oted a lack of resources was ihibitig their ability to advocate ad scale up actio for breastfeedig. A dearth of fudig has cotributed to the patter of low ivestmet low effectiveess low visibility respodets described. A lack of huma resources capacitated for IYCF advocacy, policy ad programmig was also oted. This fifth area will ivolve promotig accelerated actio ad mobilizig resources ad commitmet for accelerated actio towards achievemet of full coverage of the IYCF idicators 118. This promotio should focus ot just o the idicator of exclusive breastfeedig, but also early iitiatio of breastfeedig ad cotiued breastfeedig, as well as the complemetary feedig idicator of miimum acceptable diet ad its two compoet parts (diversity ad frequecy). It also ivolves idetifyig ad promotig ways to hold coutries accoutable for the World Health Assembly (WHA) target o exclusive breastfeedig that they siged off o 119. I additio, the importat role of improved breastfeedig ad complemetary feedig practices i addressig a umber of the other WHA targets, such as stutig ad wastig, also eeds to be accompaied by a process of greater accoutability towards progress. It was oted that a implemetatio pla related to these targets exists, but that the accoutability mechaism is ot clear. Idustrialized coutries should also be accoutable to report. I terms of measurig progress towards the achievemet of the IYCF idicators, it was oted that for most coutries data is available, for example as reported i the Coutdow Report, by UNICEF, WHO etc. However, there is eed to geerate more attetio to progress ad lack of progress. There is also a eed for more frequet, better reportig both o itervetios ad practices aually if possible. To this ed, stadard IYCF scorecards eed to be developed, agreed ad their use promoted to improve the comprehesiveess ad frequecy reportig o both the performace of IYCF itervetios ad the results i terms of IYCF practices. Prioritizatio of breastfeedig ad IYCF itervetios i terms of resources eeds to substatially icrease if the targets are to be met ad the goals of the utritio ad child survival movemets met. This may imply shiftig to greater prioritizatio for IYCF prioritizatio withi existig resource 60 BREASTFEEDING ON THE WORLDWIDE AGENDA

evelopes as well as seekig ew resources, maximizig syergies ad opportuities, directig policies ad programme desig towards greater istitutioalizatio ad sustaiability, ad esurig more focus o capacity buildig of huma resources for quality IYCF programmig ad techical skills. The icreased fiacial prioritizatio ca be reflected i atioal budgets, door support ad public-private parterships cosistet with the Code. The potetial for private sector support eeds to be carefully explored, esurig compay goals are do ot coflict with ad are aliged with those of IYCF stakeholders, ad proposals have bee fully vetted to coform to the Code ad avoid coflicts of iterest. Nutritio doors play a essetial role to advace IYCF as strategic parters, advocates ad fuders. Today they ca make all the differece by seedig ew iitiatives that spark a positive cycle of ivestmet ad attetio. Parters are motivated to work with them to defie shared idicators of progress. I terms of other opportuities to esure IYCF is strogly reflected as a target, stakeholders metioed that i the post-2015 ageda, IYCF idicators should be reflected. New research, advocacy ad commuicatio icludig prize moey for iovative approaches could be fuded. Resources ca be allocated to a rage of costituecies, icludig guidig istitutios, academics, NGO ad civil society actors such as faith-based orgaizatios ad wome s groups. Govermets eed to be motivated to positio ifat ad youg child feedig cetrally i budgets for utritio ad child survival, whether atioal resources or exteral fudig, ad whether developmet programmes or emergecy respose. UNICEF 61

ACKNOWLEDGEMENTS This aalysis of political commitmet for breastfeedig programmes was commissioed by UNICEF Headquarters Nutritio Sectio. The Ifat ad Youg Child Nutritio (IYCN) Uit iitiated the project, selected stakeholders, ad provided techical iputs ad oversight throughout the process. Uit members ivolved iclude Nue Magasarya, Seior Advisor IYCN, who provided overall leadership ad oversight; David Clark, Nutritio Specialist Legal; ad Christiae Rudert, Nutritio Specialist Ifat Feedig, who maaged the ladscape aalysis process, coducted the desk review of strategic frameworks of parterships, orgaizatios ad coutries ad edited the fial versio of the report ad associated presetatio. Willis Demas provided admiistrative support. Ruth Lady, pricipal cosultat for Strategic Commuicatio for Social Impact, coducted the stakeholder survey, prepared the report ad draft presetatio, as well as the Executive Summary. The grey literature search was coducted with assistace from two researchers Mega Mccaugha ad Daiela Serria. Desig is by Susae Weihl, folio2: desig ad brad commuicatios studio. Special thaks are due to Jeremy Shiffma, Professor of Public Admiistratio ad Policy at America Uiversity, for his support ad feedback regardig the applicatio of his framework to examie political priority for breastfeedig. Appreciatio i particular goes to all the stakeholders who were geerous with their time ad isights. Their deep experiece ad commitmet to advace breastfeedig protectio, promotio ad support were evidet throughout the cosultatio process. 62 BREASTFEEDING ON THE WORLDWIDE AGENDA

Amog ewbors, oly 43 per cet started breastfeedig withi the first hour after birth. Breastfed ifats are much less likely to die from diarrhoea, acute respiratory ifectios ad other diseases. A ewbor urses at his mother s breast at a hospital i Kabul, capital of Afghaista. UNICEF 63

ANNEX 1 STAKEHOLDERS CONSULTED Stakeholders Orgaizatio WHO & World Bak 1 Beradette Daelmas Coordiator, Policy, Plaig & Programmes 2 Chessa Lutter Regioal Advisor 3 Leslie Elder Seior Nutritio Specialist World Health Orgaizatio Geeva, Switzerlad Pa America Health Orgaizatio Washigto D.C., USA World Bak Washigto D.C. USA Doors 4 Aa Taylor Seior Nutritio Adviser Ruth Lawso Seior Health Adviser for MNCH 5 Elle Piwoz Seior Program Officer, Nutritio UK Departmet for Iteratioal Developmet (DfID) Lodo, Uited Kigdom Bill & Melida Gates Foudatio Seattle, USA NGOs & Civil Society 6 Rae Galloway Seior Nutritio Officer 7 Lua Marti Commuicatios Specialist 8 Victoria Qui Seior Vice Presidet of Programs 9 Ages Guyo Seior Advisor 10 Ali Maclaie Seior Humaitaria Nutritio Advisor 11 Domiic Schofield Director, Multi-Nutriet Supplemets 12 Lida Lhotska 13 Jeifer Mouri Artist & Activist 14 Miriam Labbok Professor of the Practice of Public Health PATH Washigto D.C., USA Alive ad Thrive Washigto D.C., USA Hele Keller Iteratioal New York, USA Joh Sow Ic. Washigto D.C., USA Save the Childre UK Lodo, Uited Kigdom Global Alliace for Improved Nutritio Washigto, D.C., USA Geeva Ifat Feedig Associatio (GIFA) Geeva, Switzerlad World Alliace for Breastfeedig Actio (WABA) Peag, Malaysia Uiversity of North Carolia Chapel Hill, USA (represetig WABA) 64 BREASTFEEDING ON THE WORLDWIDE AGENDA

Stakeholders 15 Patti Rudall Policy Director 16 Dr Aru Gupta, Regioal Coordiator Orgaizatio Baby Milk Actio Cambridge, UK IBFAN Asia, New Delhi, INDIA Idepedet Cosultats 17 Rukhsaa Haider Chairperso 18 Mary Lug aho Director Traiig ad Assistace for Health ad Nutritio Foudatio, Dhaka, Bagladesh Nutritio Policy ad Practice USA Academics 19 Jeifer Bryce Seior Scietist 20 Karlee Gribble Researcher 21 Nita Bhadari Coordiator Johs Hopkis Bloomberg School of Public Health Baltimore, USA Uiversity of Wester Sydey Sydey, Australia Cetre for Health Research ad Developmet New Delhi, Idia Global Health ad Nutritio Parterships 22 Lucy Sulliva Director 23 Carol Preser Director 1000 Days Iitiative Washigto D.C., USA Partership for Materal, Newbor & Child Health Geeva, Switzerlad UNICEF 24 Olivia Yambi Cosultat, Previous UNICEF Represetative 25 Joyce Greee Cosultat, Nutritio Sectio 26 Victor Aguayo Chief Nutritio 27 Lotta Sylwader UNICEF Represetative 28 Gillia Mellsop UNICEF Represetative Dar es Salaam, Tazaia UNICEF, New York UNICEF Idia New Delhi, Idia UNICEF Vietam Haoi, Vietam UNICEF Chia Beijig, Chia UNICEF 65

ANNEX 1 STAKEHOLDERS CONSULTED Stakeholders 29 Noree Prediville Chief Nutritio 30 Koe Vaorgmelige UNICEF Represetative 31 Dorothy Rozga UNICEF Represetative Harriet Torlesse Nutritio Maager 32 Felicite Tchibidat Seior Regioal Advisor Nutritio 33 Agela Kearey UNICEF Represetative 34 Frace Begi Seior Regioal Advisor Nutritio 35 Peter Salama UNICEF Represetative 36 UNICEF Nigeria collective reply 37 UNICEF Egypt collective reply 38 UNICEF Ugada collective reply 39 UNICEF Yeme collective reply Orgaizatio UNICEF Bagladesh Dhaka, Bagladesh UNICEF Agola Luada, Agola UNICEF Tazaia, Dar es Salaam, Tazaia UNICEF West & Cetral Africa Regioal Office Dakar, Seegal UNICEF Idoesia Djakarta, Idoesia UNICEF East Asia & Pacific Regioal Office Bagkok, Thailad UNICEF Ethiopia Addis Ababa, Ethiopia UNICEF Nigeria Abuja, Nigeria UNICEF Egypt Cairo, Egypt UNICEF Ugada Kampala, Ugada UNICEF Yeme, Saa a, Yeme 40 UNICEF Mozambique collective reply 41 UNICEF South Africa collective reply 42 UNICEF Ira collective reply 43 UNICEF Philippies collective reply 44 UNICEF Pakista collective reply UNICEF Mozambique Maputo, Mozambique UNICEF South Africa Pretoria, South Africa UNICEF Ira Tehra, Ira UNICEF Philippies Maila, Philippies UNICEF Pakista Islamabad, Pakista 66 BREASTFEEDING ON THE WORLDWIDE AGENDA

ANNEX 2 Questioaire Stakeholder Questioaire: Political Commitmet to protect, promote ad support breastfeedig practices Itroductory Note Exclusive breastfeedig i the first six moths ad cotiued breastfeedig up to 1 year is the sigle most effective itervetio for prevetig child deaths, yet less tha 40 percet of ifats uder 6 moths old are exclusively breastfed i developig coutries ad there has bee egligible improvemet globally sice 1990. For the purposes of this questioaire, we defie political commitmet 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 problem s severity. Political commitmet ca be measured by: Leadership Global ad atioal leaders publicly ad privately express sustaied cocer about a issue Policies & Programmes Global orgaizatios ad govermets formally eact policies ad programmes that offer widely embraced strategies to address the problem Resourcig Iteratioal orgaizatios, doors, govermets, civil society ad other stakeholders allocate ad release fudig commesurate with the problem s severity Questioaire The Situatio Today 1. How would you rak the curret state of global political commitmet to programmes to protect, promote ad support improved breastfeedig practices, i relatio to their potetial impact o child survival? (If you work at the coutry level, what is curret state of govermet commitmet?) Rak o a scale of 1 10, with 10 beig the highest level of commitmet. Please explai your rakig. 2. How would you evaluate the impact of existig advocacy iitiatives to icrease political ad door commitmet for programmes to improve breastfeedig practices? Please share ay evidece you are aware of o this subject. 3. Is there a eed to icrease the level of political advocacy ad commitmet for breastfeedig at the global level ad i coutries? If yes, why? UNICEF 67

4. How do you thik programmes to improve breastfeedig practices are curretly prioritized by your orgaizatio relative to other utritio ad family health priorities? What are the uderlyig reasos for this? 5. Ay other key poits ad issues you would like to share regardig the curret situatio with regard to advocacy, commitmet ad prioritizatio for breastfeedig? Barriers 6. Please rak the sigificace of the followig factors which may be prevetig orgaizatios ad govermets from makig breastfeedig programmes a higher priority. Rak from most to least importat: Lack of evidece that programmes ca be implemeted at scale Perceptio that breastfeedig is ot a importat priority Perceptio that stakeholders lack a uified strategy to address the problem Perceptio that breastfeedig is a less reliable health ad utritio ivestmet sice it s based o a behavioural itervetio rather tha a product Other factors? 7. Ay other key poits ad issues you would like to share regardig the barriers to prioritizatio of programmes to improve breastfeedig? Opportuities 8. What opportuities curretly exist to raise awareess ad build commitmet for breastfeedig as a key child survival ad utritio itervetio? How would you recommed advocacy strategies related to breastfeedig take best advatage of these opportuities? 9. Please rak the importace of the followig factors i buildig political ad door commitmet for breastfeedig programmes: evidece that programmes work at scale leadership powerful ideas (the way advocacy approaches tell the story) guidig istitutios 68 BREASTFEEDING ON THE WORLDWIDE AGENDA

other factors? Provide a explaatio for your rakig ad add other factors you prioritize. 10. Ay other key poits ad issues you would like to share regardig opportuities? The Way Forward 11. What are the greatest eeds today, i terms of advacig breastfeedig advocacy at the global level? 12. At the coutry level, what type of breastfeedig advocacy is likely to have the most impact o atioal programmes? 13. What key factors would motivate political leaders ad doors to prioritize breastfeedig? 14. How effective do you thik a advocacy strategy would be if it were focused solely o mobilizig support ad resources for breastfeedig (a vertical approach) versus icludig breastfeedig withi a itegrated package of itervetios? If you favour a itegrated approach, what actios do you recommed to esure this priority is ot lost withi broader agedas? 15. What ext steps do you recommed to advace this process? 16. Ay other key poits ad issues you would like to share regardig the way forward? A fial request: Data o fudig for breastfeedig protectio, promotio ad support Does your orgaizatio have disaggregated data showig curret programme or door expeditures to improve breastfeedig practices? If so, would you be willig to research ad provide us with this iformatio? Our goal i makig this request is to put together a more comprehesive picture of overall support for breastfeedig programmes, ad share this with you. UNICEF 69

ANNEX 3 STAKEHOLDER PROPOSALS FOR STRENGTHENING THE BREASTFEEDING INVESTMENT CASE Breastfeedig helps develop ecoomies ad huma capital Focus o the impact o productivity ad ecoomic developmet ad decreasig chroic diseases, so there is less drai o health services. (Q3) Build o the work doe by PROFILES, to estimate the ecoomic loss due to malutritio (icludig low BF rates) ad presets costig eeds to esure >95 per cet childre are esured the right to BF. (Q13) Upack the package of IYCF itervetios. We keep talkig about this importat package of direct utritio itervetios i the SUN ad 2008 Lacet series, but we eed to prioritize. The Miister of Fiace is goig to wat to kow what are the top 3 thigs he should focus o, ot the top 13 or 15. (S2) Take a middle approach strog ew emphasis o IYCF withi a stutig cotext that combies eed for behavioural ad commodity-based approaches ad icludes a strog operatioal research compoet. Esure likages to broader child survival ageda ad multi-sectoral utritio ageda of SUN are very clear. (Q10) For coutries with low exclusive breastfeedig rates, budget the cost of scalig up peer couselig ad other itervetios ad the potetial retur i terms of lives saved. (Q2) Breastfeedig brigs health ad lifestyle beefits to mother ad child Commuicate that breastfeedig is the sigle most importat itervetio to prevet ifat mortality, has a large protective effect o eoatal mortality, prevets short ad log-term child morbidity ad icreases IQ. Wome who breastfeed also have reduced risk of ovaria ad premeopausal breast cacer ad cardiovascular disease. (Q1) Promote the health beefits of breastfeedig i relatio to prevetig o-commuicable diseases, icludig obesity. Highlight the risks of formula feedig icludig sugar cotet i ifat formula, which may people do t realize is there. (S12) Lik breastfeedig to the cosumer movemet for healthier lifestyles, where citizes demad better products ad better services from their govermets. (S10, S15) Breastfeedig saves ewbor lives ad promotes early childhood developmet Capitalize o door iterest i ewbor health, ad the potetial of early iitiatio of breastfeedig to reduce eoatal mortality. (S1) 70 BREASTFEEDING ON THE WORLDWIDE AGENDA

Embed breastfeedig i the cotext of early child developmet, ad lik back to developmet of huma capital. (S2) Breastfeedig improves child learig ad future success i life Make breastfeedig aspiratioal by stregtheig the evidece base o the impact it has o a child s itellectual, health, ad emotioal developmet. That will really make a impact i emergig ecoomies. (S20) Lik breastfeedig ad utritio to families priorities goig to school, learig, succeedig ad breakig the iter-geeratioal karma of deprivatio. (S18) Formula feedig has ivisible costs for families, atios ad the eviromet Track how may babies die every year from sub-optimal breastfeedig ad cost fiacial burdes o govermet budgets due to formula-related child morbidity ad mortality. (S6) Calculate the evirometal cost of formula feedig with breastfeedig from productio costs through the carbo footprit to ship formula aroud the world, the cost of heatig water ad discarded tis. (S11) Documet ad quatify Code violatios i specific coutries, such as umbers of health workers give formula samples ad asked to promote it. (S1) I discussig the public positioig of breastfeedig, stakeholders also had the followig recommedatios: Reach out to the wome s health ad geder commuities to dialogue about the barriers wome face to breastfeed ad advocate joitly for better materity protectio. (S2) Egage with civil society costituecies with shared values ad goals, icludig parliametarias, faith-based orgaizatios ad youth. Defie ad propose idicators to measure govermet ad door accoutability for meetig their commitmets to support breastfeedig, so these become more tha mere declaratios of priciple. (S8) Icrease policy makers kowledge regardig the idicators they eed to use for moitorig the effectiveess of programmes. Curretly, there is little demad for this iformatio, limitig political leaders ability to track progress. (S1) Ivest i high quality marketig ad advertisig, icludig services of private sector compaies, sice this is essetial to chage social orms ad promote behavior chage i today s marketplace. (S8) Scale up the use of cell phoe techology ad social media to reach youg wome ad their families for breastfeedig promotio ad support. (S2, S16, S24, Q16) UNICEF 71

ANNEX 4 ORIGINAL FRAMEWORK PROFESSOR JEREMY SHIFFMAN Category Factor Explaatio Why It Matters Examples Actor Power 1 Policy commuity cohesio Coalesce amog etworks; multiple types of orgaizatios Ehace authority Positive shift i materal commuity 2 Leadership Strog champios for the cause; they defed the issue, ispire actio, brig together the policy commuities Defiig the issue, ispire actio, brig together the policy commuities Jim Grat for child survival 3 Guidig istitutios Coordiatig mechaisms Sustaiability Natioal AIDS commissios Ideas 4 Civil society mobilizatio 5 Iteral frame Egaged social istitutios that press political authorities to act Commo policy commuity uderstadig of problems ad solutios Source of exteral pressure Avert fractiousess, ehace credibility TB commuity coalesce aroud DOTS 6 Exteral frame Public positioig of the issue that ispires exteral audiece to act Oly some resoate widely; differet frames resoate with differet audieces Case of HIV/AIDS; Fiace miisters v. health miisters Political Cotext 7 Policy widows Momet i time whe coditios alig favourably for a issue; ofte follow disasters, discoveries, forums; At atioal level may follow regime chages Preset widows of opportuity MDG s 8 Existig health priorities Priority for other health issues May facilitate of divert policy-maker attetio Newbor survival i Nepal ad Bagladesh; Door prioritizatio of AIDS Issue Characteristics 9 Severity Size of burde relative to other problems; Credible INDICATORS are the key Prefereces for causes perceived to be serious; idicators alarm politicias DHS idicators for materal health 10 Tractability Extet to which problem is (perceived to be) surmoutable; CLEAR, COST- EFFECTIVE INTERVENTIONS are key Policy-makers are more likely to act o issues they thik they ca do somethig about Immuize childre 11 Dager Degree to which problem is perceived to pose a threat; especially to rich people Pressure for immediate actio to cotai threat SARS v. peumoia 12 Cotetiousess Extet to which addressig the issue icites oppositio Ihibits progress; ispires actio Reproductive health ad church i Lati America 13 Culpability Degree to which those with the coditio perceived to be resposible Reluctat to act if perceived idividual resposibility aloe; eed to shift locus of resposibility to society Obesity v. malutritio 14 Allure Attractiveess of the issue to those who might wat to address it Reputatioal effects AIDS vs. diarrheal diseases 72 BREASTFEEDING ON THE WORLDWIDE AGENDA

ACRONYMS A&T Alive ad Thrive MDGs Milleium Developmet Goals ACF Actio Cotre la Faim (Actio Agaist Huger) MNCH materal, ewbor ad child health AED Academy for Educatioal Developmet MTSP medium term strategic pla AIDS acquired immue deficiecy sydrome NGO o-govermetal orgaizatio APR A Promise Reewed OFDA Office of Foreig Disaster Assistace BF breastfeedig (Uited States govermet) BFHI Baby Friedly Hospital Iitiative PAHO Pa America Health Orgaizatio CCCs Core Commitmets for Childre i Humaitaria Actio PMNCH Partership for Materal, Newbor ad Child Health CIFF DFID DOTS EMR ENA ENN EU FAO Childre s Ivestmet Fud Foudatio Departmet for Iteratioal Developmet (Uited Kigdom) directly observed therapy, short-course Easter Mediterraea essetial utritio actios Emergecy Nutritio Network Europea Uio Food ad Agriculture Orgaizatio REACH SPRING SUN TB UK UN UNHCR Reewed Effort Agaist Child Huger ad uderutritio Stregtheig Parterships, Results ad Iovatios i Nutritio Globally Scalig Up Nutritio tuberculosis Uited Kigdom Uited Natios Uited Natios High Commissioer for Refugees GAIN Global Alliace for Improved Nutritio UNICEF Uited Natios Childre s Fud gbics global Breastfeedig Iitiative for Child Survival US Uited States HIV huma immuodeficiecy virus USAID Uited States Agecy for Iteratioal HKI Hele Keller Iteratioal Developmet IBFAN Iteratioal Baby Food Actio Network USG Uited States Govermet ICDC Iteratioal Code Documetatio Cetre WABA World Alliace for Breastfeedig Actio IFAD Iteratioal Fud for Agriculture Developmet WASH water, saitatio ad hygiee IFE ifat feedig i emergecies WBTi World Breastfeedig Treds Iitiative IYCF ifat ad youg child feedig WFP World Food Programme IYCN ifat ad youg child utritio WHA World Health Assembly JSI Joh Sow Icorporated WHO World Health Orgaizatio UNICEF 73

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