Have policy makers expressed commitment to scale up in-country breastfeeding efforts?
Political will “exists when a sufficient set of decision makers with a common understanding of a particular problem on the formal agenda is committed to supporting a commonly perceived, potentially effective policy solution”. According to Post et al., this complex, multifactorial phenomenon is comprised of three factors, which help conceptualize political will:
a) the distribution of preferences of policymakers (i.e. what are the preferences of acting politicians and will others accept the policies);
b) the authority, capacity, and legitimacy of key decision makers or reformers (i.e. political will is only strong if political power and resources are available); and
c) commitment to preferences (i.e. how a policymaker stands up for his/her beliefs; how resources and other efforts are allocated; what incentives/disincentives are provided to the policymaker for adopting a position).
The Breastfeeding Gear Model (BFGM) posits that the Political Will Gear results when advocacy is strong enough to generate momentum that elicits political commitment from policy makers to protect, promote and support breastfeeding. In turn, strong political will is needed to enact legislation and policies to protect, promote and support breastfeeding. Only when expressed commitment - “verbal declarations of support for an issue by high-level, influential political leaders”, institutional commitment - policies and organizational infrastructure, and budgetary commitment- monies have been allocated towards a particular cause are all present is there full and complete political commitment towards a cause, such as breastfeeding.
Measuring political will is complex and indirect, typically by examining the political commitment of decision makers. While political commitment is comprised of “expressed commitment”, “institutional commitment” and “budgetary commitment”, these reflect separate gears within the BFGM corresponding to “political will”, “legislation and policies”, and “funding & resources” respectively. Thus, measuring political will for the BFGM consists of evaluating the level of expressed commitment policymakers have towards scaling-up breastfeeding.
The theme for the Political Will Gear measures expressed commitment by the government to protect, promote and support breastfeeding scaling up efforts. This one theme, expressed commitment, is assessed by three benchmarks.
All benchmarks are referenced to “the past year” unless otherwise noted.
Post LA, Raile ANW, Raile ED. Defining Political Will. Politics & Policy. 2010;38:653-676.
Expressed Commitment Theme
PWG1: High level political officials have publicly expressed their commitment to breastfeeding action
This benchmark assesses whether there has been any public expression of commitment or promise by at least two government officials to move forward with implementing breastfeeding activities. High level political officials can be within federal and/or state government.
"Public expression”: Verbally expressing commitment to furthering breastfeeding activities to the public and it captures substantial media attention.
“High level political official”: Someone within the federal and/or state government with the capacity to influence policy decisions at the national levels including the country leader, first lady/spouse, policy makers etc.
“Breastfeeding action”: Activities that protect, promote and support breastfeeding.
Possible data sources: Media data sources may be the best source to evaluate this benchmark. Media sources can include social media announcements or articles (i.e. Facebook, Twitter, Instagram, etc.), newspaper articles, radio or TV stories, transcripts, etc.
The scoring for this benchmark reflects the number of times high level political officials have expressed their commitment to breastfeeding action within past year. To assess the difference between minimal and partial progress, the high level political officials must have publicly spoken about breastfeeding AND expressed their commitment to action.
How to score:☐ No progress: High level political officials have not publicly expressed their commitment to breastfeeding action at all.☐ Minimal progress: High level political officials have publicly spoken about breastfeeding but have not expressed their commitment for action.☐ Partial progress: High level political officials have publicly expressed their commitment to breastfeeding action once.☐ Major progress: High level political officials have publicly expressed their commitment to breastfeeding action at least twice.
Example: First Lady Michelle Obama launched a breastfeeding campaign to support nursing mothers. The campaign recognizes the health benefits of breastfeeding and identifies its association with lowering the risks of childhood obesity, which coincides with Mrs. Obama’s “Let’s Move!” initiative. Mrs. Obama said that early intervention, including breastfeeding, was key in preventing obesity. She cited needing more breastfeeding education, specifically for women in predominately black communities, according to Mrs. Obama, “40% of [black] babies never get breastfed at all.” She also has pushed for more hospitals to be certified as “Baby Friendly” and more flexible workplace rules for breastfeeding. Mrs. Obama has been very open about breastfeeding her own children and this is generally recognized to be the first person in the US with the First Lady's stature or power that has embraced breastfeeding so publicly.
Mrs. Obama has publicly expressed her commitment to breastfeeding action multiples times throughout the year.
Score: Major Progress
Domain-Volume: US First Lady is considered a high-level official and she verbally promoted breastfeeding more than two times in one year.
Domain-Quality : Mrs. Obama publicly expressed her commitment to action by including breastfeeding in her obesity initiative.
PWG2: Government initiatives have been implemented to create an enabling environment that promotes breastfeeding.
An enabling environment that promotes breastfeeding is essential to successful scaling up of breastfeeding. This enabling environment refers to an atmosphere that encourages breastfeeding and discourages alternative feeding methods.
An enabling environment for breastfeeding includes interventions/initiatives related to:
- Social mobilization and mass media;
- Legislation, policy, financing, monitoring, and enforcement; and
- Counselling, support, and lactation management.
Enabling interventions operate by removing structural and societal barriers that interfere with women’s ability to breastfeed optimally (Rollins et al., 2016). Examples of enabling interventions can include:
- Maternity and workplace policies or regulations to restrict marketing of breast milk substitutes;
- Health insurance or other financing mechanisms for lactation support; and
- Baby-friendly hospital certification (Rollins et al., 2016).
This benchmark assesses whether national government initiatives (such as agenda setting, policy development and program(s) support events) have been implemented to foster an enabling environment for successful scaling up of breastfeeding programs. Government led initiatives can cross multiple sectors including training, legislation, promotion, etc.
Possible data sources: To assess this benchmark, interviews with government sources familiar with breastfeeding or infant/young child feeding initiatives can generate the information needed to score this benchmark. Written reports, guides, program descriptions from government agencies and NGOs working in maternal and child nutrition can also provide valid information to assess this benchmark. Any written materials need to be linked to initiatives that have been started within the past year.
For scoring this benchmark it is important to:
- Identify the specific barriers in the country to improving breastfeeding practices;
- Identify enabling initiatives that have been implemented; and
- Match those initiatives necessary to enable the breastfeeding environment that have actually been implemented (i.e., level of implementation) with how they have impacted the enabling of a breastfeeding-friendly environment (i.e., quality of the enabling environment).
The scoring of this benchmark reflects the level of implementation and the quality of the enabling environment in the past year.
How to score:☐ No progress: No government initiatives have been implemented to create an enabling environment that promotes breastfeeding.☐ Minimal progress: A few government initiatives have been implemented but they do not create an enabling environment that promotes breastfeeding at the national level.☐ Partial progress: Several government initiatives have been implemented and they have started to create an enabling environment that promotes breastfeeding at the national level, i.e. for the government initiatives being implemented, some are beginning to create an enabling environment.☐ Major progress: Several government initiatives have been implemented and they have created a strong enabling environment that protects, promotes and supports breastfeeding at the national level.
Example: In 2016, Mexico BBF committee considered the initiatives that enable a breastfeeding environment, i.e. those actions that the government implemented to eliminate barriers to breastfeeding in Mexico. Six specific barriers and initiatives were identified through the literature:
1) Barrier: Type of birth and inadequate hospital practices (e.g. formula feeding during post-birth recovery). Impact: Progress has been made in certifying baby-friendly hospitals. As of April 2016, 107 hospitals were nominated, an advance of almost 30% over the target but the levels are still low nor has BFHI been implemented in health centers.
2) Barrier: Lack of breastfeeding counseling. Impact: 84.6% of mothers know at least one benefit of breastfeeding and 88.6% have received pre or postnatal breastfeeding counseling. However, it is unclear if counselors are trained and whether the counseling itself is pro-breastfeeding.3) Barrier: Lack of efficient health care and cross cultural support, mainly for indigenous and rural communities. Impact: 87.3% indigenous mothers were visited 5 times in the prenatal period by a trained health worker. This data does not provide information on the efficiency of the care or it’s specific reference to multiculturalism.
4) Barrier: Lack of appropriate spaces for breastfeeding when women return to work. Impact: Guidance was issued to address this but few companies have appropriate spaces for breastfeeding.
5) Barrier: Lack of laws to protect lactation among working women. Impact: BBF Committee agrees that while on the paper there are advances, in reality these laws have not been implemented.
6) Barrier: Lack of monitoring of the compliance of the International Code. Impact: Government has relied on self-regulation by the formula industry and does not monitor nor has an action plan to better implement the Code.
Score: Partial Progress
Domain- Existence: Yes
Domain- Effective: Several government initiatives have been implemented and they have started to create an enabling environment that promotes breastfeeding at the national level.
Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, Richter LM, Victora CG; Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016 Jan 30;387(10017):491-504. doi: 10.1016/S0140-6736(15)01044-2.
PWG3: An individual within the government has been especially influential in promoting, developing, or designing breastfeeding policy.
This benchmark assesses whether there is an individual within the government (which includes all individuals working within the government regardless of being elected, appointed, or hired on a temporary basis) who has been the driving force behind promoting, developing, or designing breastfeeding policy.Promoting: Introducing and supporting the creation of breastfeeding policy.
Developing: Active involvement in the generation of a breastfeeding policy.Designing: Active involvement in the writing of the breastfeeding policy.
Data sources: To assess this benchmark, interviews with government sources familiar with breastfeeding or infant/young child feeding initiatives can generate the information needed to score this benchmark. Written reports, guides, program descriptions from government agencies and NGOs working in maternal and child nutrition can also provide valid information to assess this benchmark.
The scoring for this benchmark reflects the existence and the level of influence a government individual or a collective group of individuals has in promoting, developing, or designing breastfeeding policy. To assess this, map all the individuals working on the breastfeeding policy. Then, map all the activities they undertook towards promoting, developing or designing the policy.
Minimally influential: Individual or a collective group of individuals has had only a little impact on the promotion, development, or design of breastfeeding policy over the past year. In this situation, breastfeeding policy is being promoted, but it hasn’t been developed.
Partially influential: Individual or a collective group of individuals has had more impact on the promotion, development, or design of breastfeeding policy over the past year. In this situation, breastfeeding policy has been promoted and developed but not implemented.
Strongly influential: Individual or a collective group of individuals has had a strong impact on the promotion, development, or design of breastfeeding policy over the past year. In this situation, the breastfeeding policy has been promoted, developed and implemented.
How to score:☐ No progress: There is no individual or collective group of individuals within the government who has been influential in promoting, developing, or designing breastfeeding policy.☐ Minimal progress: There is an individual or a collective group of individuals within the government who has been minimally influential in promoting, developing, or designing breastfeeding policy.☐ Partial progress: There is an individual or a collective group of individuals within the government who has been partially influential in promoting, developing, or designing breastfeeding policy.☐ Major progress: There is an individual or a collective group of individuals within the government who has been strongly influential in promoting, developing, or designing breastfeeding policy.
Example: Senator Cayetano of the Philippines is an example of a breastfeeding champion who has used her position in the national government to protect, promote, and support women’s right to breastfeed. She was the principal author of the Expanded Breastfeeding Promotion Act and sponsored the Expanded Maternity Leave Bill, developed by the Senate Committee on Women, of whom she is Chair. She also: a) sponsored a bill to ensure there is one midwife in every health station per 5,000 people, in order to help the Philippines reach its Millennium Development Goal of improving maternal and neonatal health outcomes, b) a resolution asking the legislature to launch an inquiry into Milk Code violations and c) succeeded in getting “gender provisions’ into the ‘Philippine Disaster Risk Reduction and Management Act of 2010’.
Score: Major Progress
Domain- Existence: Yes
Domain- Effective : Senator Cayetano had a strong level of impact on promoting, developing and implementing expansion of the maternity leave legislation.