The Alive & Thrive project designed three comprehensive IYCF programs in Bangladesh, Ethiopia, and Viet Nam with the aim of developing models that could be scaled up globally. Evidence-based advocacy for enabling policy change, building alliances to secure investments for IYCF, and establishing partnerships to scale up and sustain IYCF program activities were an integral part of the program in each country. A systematic process comprising situational analysis, stakeholder consultations, and opinion leader research led to articulation of national advocacy goals and strategies for each of the three countries. While comprehensive in their approach to IYCF, exclusive breastfeeding for the first six months of life was a main tenant held, advocated in all programs, and will be the focus of this case study.
Description & Context
To reduce childhood nutrition gaps in Bangladesh, Ethiopia, and Viet Nam, the Alive & Thrive (A&T) initiative designed three comprehensive IYCF programs with the aim of developing models that could be scaled up globally
In Viet Nam, stakeholder analysis, stakeholder consultation and opinion leader research identified the key challenges for bringing about optimal IYCF practices and the critical individuals and groups necessary to engender change. Research showed that only 20% of babies were breastfed exclusively for the first 6 months and 22% up to 24 months and that mothers named going back to work as a primary reason for ceasing breastfeeding. As women made up 48% of the workforce, the need for two more months paid maternity leave was clear. A&T utilized the extensive research base they amassed to effectively advocate for extended maternity leave and in 2012, Viet Nam’s National Assembly extended paid maternity leave from 4 to 6 months –it passed with more than 90% of votes.
In Bangladesh, the research found there was a lack of knowledge about IYCF practices and their impact on malnutrition within the country amongst policy makers and the more educated populace. The landscape analysis identified the media as likely to have the greatest impact on increasing knowledge and influencing policy decisions. In order to utilize this resource more effectively, A&T embarked on a media engagement program to enhance capacity of health reporters to conduct in-depth reporting with journalist training, increase the availability and use of new data to drive decision making and program delivery, and improve news editors’ and news directors’ commitment to covering IYCF and child nutrition.
In Ethiopia, overall food scarcity rather than poor IYCF practices, were viewed as the main reason for malnutrition. A&T focused on promotion and prevention, working in collaboration with the Ministry of Health. As part of the Accelerated Reduction of Stunting Workshop in 2011, investing in IYCF became a core intervention and was incorporated it into health program delivery and social protection and food security strategies. As a result, international agencies built IYCF into their programs. In order to increase visibility at the regional levels, A&T ran workshops on stunting reduction for regional government officials and leaders of Women’s Associations.
To determine the advocacy goals, strategies and potential partners for protecting, promoting, and supporting IYCF programs in Viet Nam, Bangladesh and Ethiopia, A&T followed these steps:
1. Situational analysis:
A&T teams carried out desk-based research on existing documentation of the policy environment, review of policy documents, overview of the key actors, and compilation of data on IYCF practices from secondary sources such as Demographic Health Surveys. The findings were then analyzed and organized based on the major themes of the conceptual framework for this literature review. Data on IYCF practices from both government and NGO sources were used.
The reviews had three objectives:
- To document the patterns and trends in IYCF;
- To review the barriers and facilitators to IYCF practices; and
- To review policies and programs related to IYCF.
Literature search methods:
- Electronic databases – PubMed and Google Scholar;
- Official websites of organizations for non-peer reviewed papers and program reports
- Unpublished reports from the government and NGO libraries;
- Studies/reports - survey and surveillance reports; descriptive studies on IYCF practices and nutrition; studies on interventions to improve IYCF practices; and
- Official documents describing the policies and programs from the Ministry of Health (MoH).
Data extraction methods:
- Demographic Health Survey (DHS): for example, in Viet Nam the DHS is a nationally representative survey of ever-married women 15-49 years old selected from sampling clusters throughout the country;
- NIN surveillance- nationally representative surveillance data collected to assess status and trends in the nutritional status, quality of child feeding, and health care for children under 5 years of age; and
- Viet Nam Multiple Indicator Cluster Survey - nationally representative surveys and data/information on the situation of children and women in Viet Nam.
The information on government programs, policies, and strategies in relation to IYCF was organized chronologically to depict the evolution of IYCF policy in-country.
The conceptual framework used for this review was adapted from Labbok and Taylor (Reference 3) and sets out the main factors that influence IYCF. For example, in Viet Nam, these were:
- Political/social factors - national health, nutrition policy, and international support;
- Health care providers’ knowledge, attitude, and level of support for optimal IYCF practices;
- Community/family influence on IYCF based on cultural beliefs, ethnicity, and food availability; and
- Mothers/caregivers decisions - based on knowledge, education level, socioeconomic status, age, occupation, and health status.
- To identify the barriers and facilitators to IYCF practices all the gathered information was synthesized around these four themes.
2. Formative and opinion leader research:
- Vietnam: an independent media agency undertook a media audit to evaluate the extent of marketing and advertising of breastfeeding, infant formula, and related products. The audit identified typical violations and gaps in enforcement of the Milk Code (Decree 21).
- Bangladesh: a comprehensive media scan helped to understand the demographic reach of national media outlets and the extent of marketing of breastmilk substitutes. Further media analysis and one-on-one interviews with reporters, media experts, and NGO leaders provided a deeper understanding of the existing coverage on IYCF and what opportunities were available to improve both the quantity and the quality of public information.
- Local research agencies were contracted to design and conduct opinion leader research:
- Measure current awareness of nutrition among key influencers (political, cultural, and health);
- Identify national and sub-national priorities;
- Identify policy barriers and opportunities to improve IYCF policies, programming, and investments;
- Determine motivations and messages to increase support for IYCF;
- Identify appropriate messengers, communication channels, and points of engagement with opinion leaders. (See page 6 for more in-country detail)
- Lessons learned: Research agencies need strong country knowledge, a good reputation, and established government relationships. Alive & Thrive provided strategic technical assistance with design of the research tools and interpretation and presentation of findings. (See Other Resources for useful guides).
3. Stakeholder consultations and analysis:
- Rounds of discussion with government partners and other stakeholders to better understand the current status of IYCF advocacy initiatives, successes or failures with previous efforts, risks, areas of potential interest and collaboration among partners.
- Review of stakeholder’s institutional responsibilities.
- Vietnam: additionally, carried out a review of the legislative process and a mapping exercise to determine levels of influence and involvement of the key actors in the policy and decision-making process.
4. Goals and strategies:
- Identify critical interfaces for change.
- Gather and triangulate all information and data to develop policy and advocacy goals tailored to each country’s context.
- Prioritized two to three goals that were immediately relevant and had potential for success within the project timeframe.
- Identify activities and tactics with the potential to bring about change.
- Identify core set of advocacy partners that could contribute human, financial, and technical resources to execute the strategies.
- Lessons learned:
- Strategies must be grounded in the existing country context - and what has previously been done - and tailored to the local stakeholders (government, NGOs, civil society, professional bodies, thought leaders, business leaders, and media gatekeepers); and
- One person or dedicated group is likely to be less effective than collaborative efforts and alliances, which should be built on existing in-country partnerships and leveraged into current global initiatives. Integrating IYCF advocacy with other advocacy efforts enables harmonization of activities and resources for a higher return on investment.
Evidence of Implementation Strategy
As the final step in developing a national advocacy strategy, A&T designed an evaluation strategy based on the framework by Shiffman and Smith (Reference 2). Data collection included a stakeholder-influence mapping method called Net Map analysis, along with document review and stakeholder interviews. This data was collected again three years later. The country teams planned to use event tracking to analyze and understand the causes of any shifts in the overall policy environment during the project timeframe.
Additional evaluations were carried out on specific innovations in the advocacy strategies, for example, the provincial nutrition planning support activities in Vietnam (stakeholder interviews and content analysis of provincial nutrition plans) and the media engagement strategy in Bangladesh (media content analysis and stakeholder interviews).
Cost and cost-effectiveness
Research-based approaches to advocacy design required financial resources to hire research consultants and host meetings, human resources to develop the partner relationships necessary to inform the landscape analysis and to manage the overall design development process, and technical resources to ensure that best practices were used and communicated throughout the process. The return on these investments was high, as experience across the three countries shows that using an evidence-based design approach can advance the IYCF agenda in a relatively short time span.
Perceptions and experiences of interested people
One of the main barriers A&T found to implementing an advocacy program was the opinion leader and policy maker’s lack of knowledge about the impact of exclusive breastfeeding and complementary feeding including the significant research and proven interventions related to IYCF. Because of this, stakeholders did not see it as a top priority. A&T used targeted and evidence-based advocacy to raise policy maker and civil society understanding of IYCF to garner consensus, sustained commitment, and support. Priorities clearly shifted after A&T’s national advocacy implementation: In Bangladesh, the prime minister made several public speeches highlighting her commitment to nutrition and nutrition policies, which was later evidenced in her leadership in extending paid maternity leave in Bangladesh to 6 months for government workers. In Ethiopia, the Ministry of Health convened the Accelerated Reduction of Stunting Workshop in 2011, resulting in the revision of the National Nutrition Program, incorporating IYCF in health program delivery and social protection and food security strategies. NGO and donor organizations then prioritized IYCF in their strategies and programs.
Benefits and Potential damages and risks
Exclusive breastfeeding for the first 6 months of life is the single most effective intervention for preventing child deaths. Exclusive breastfeeding—breastfeeding only with no additional foods or liquids, including water—can improve a child’s future growth, development, educational achievement, and even economic status (Alive & Thrive).
Scaling up considerations
- “In the past, a core group of breastfeeding champions led by dedicated, respected individuals engaged policy makers to ignite change. In the face of competing priorities, the demands of advocacy are too unwieldy for one entity to achieve goals. Therefore, individual personality-driven advocacy is giving way to collaborative efforts and alliances. Building on existing in-country partnerships and leveraging global initiatives is critical to designing an effective advocacy strategy. Integrating IYCF advocacy with other ongoing advocacy efforts enables harmonization of activities and resources for a higher return on investment, and must be considered in scaling up.” (Hajeebhoy N.)
- “Program design, advocacy goals, strategies, tactics, and messages should build on the existing country context and what has already been done, and tailored to local actors spanning governments, NGOs, civil society, professional bodies, thought leaders, business leaders, and media gatekeepers. Strategies should be highly adaptive to needs and opportunities as they arise.” (Hajeebhoy N.)
Barriers to implement
- Within each country context, professional and representative associations can be critical advocacy partners, but with highly variable influence and output. Therefore, other groups—including labor and religious organizations must be utilized in the advocacy strategy. Although these groups fit the ideal advocacy model of using higher-profile champions to be the voice of an issue with opinion leader audiences, their relative influence, technical ability, and personal commitment can be difficult to ascertain in the formative stages of designing an advocacy strategy
- Sufficient human, financial, and technical resources are needed to design tailored, country-level advocacy strategies
- Identifying and contracting with research firms with a demonstrated interest and experience in conducting opinion leader research was a challenge as this type of qualitative research—especially with influential audiences—is an emerging discipline. Moreover, working with a research consultant from outside the target country is not an ideal option, as this type of research requires strong country knowledge, a good reputation, and established government relationships on the part of the executing research partner. As a result, strategic technical assistance was required to build the capacity of national research firms for design of the research tools, including questionnaires and discussion guides, and the interpretation and presentation of findings.
- Hajeebhoy N., Rigsby A., et al. Developing Evidence-based Advocacy and Policy Change Strategies to Protect, Promote, and Support Infant and Young Child Feeding. (2013). Food and Nutrition Bulletin 34: 3. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/15648265130343S205
- Shiffman J, Smith S. Generation of Political Priority for Global Health Initiatives: A framework and case study of maternal mortality. (2007). Lancet 370: 1370–9.
- Labbok, M. H., Taylor E. Achieving Exclusive Breastfeeding in the United States: Findings and Recommendations. (2008). Washington, D.C: United States Breastfeeding Committee.
- Horton S, Sanghvi T, Phillips M, Fiedler J, Perez-Escamilla R, Lutter C, Rivera A, Segall-Correa AM. Breastfeeding promotion and priority setting in health. (1996). Health Policy Plan 11:156–68.