Implementation of the Global Strategy on Infant and Young Child Feeding at national level in the African Region: Challenges and way forward
The Global Strategy for Infant and Young Child Feeding (IYCF) aims to address inappropriate infant feeding practices. Although breastfeeding of infants aged up to six months has increased in sub-Saharan Africa over the last decade the regional average is 31% (as compared with a global average of 37%). Numerous other problems impact upon child feeding in the Region. To address this issue, over 30 of the 46 countries in the WHO African Region are implementing national strategies. This paper reviews the development and implementation processes of national strategies, identifying the challenges and proposing a way forward to improve infant and young child feeding practices in the Region. Effective coordination of all the agencies concerned is identified as a key to effective implementation. The under-six month breast feeding rate has improved in most countries that have implemented IYCF strategies. Capacity building of health workers, and evaluation of strategies have played an important role in this regard. However, challenges remain – notably inadequate funding, high turnover of staff and bureaucratic delays. Establishing and sustaining community involvement has also proved difficult. A key to making progress is to enact the International Code of Marketing Breastmilk Substitutes into national law – as clearly shown by Ghana. Implementing national communication and capacity building plans also plays a vital role in improving IYCF. Addressing this issue will be critical to attaining MDG 4 on infant mortality.
La stratégie mondiale pour l’alimentation du nourrisson et du jeune enfant (ANJE) vise à résoudre le problème posé par des pratiques inadéquates d’alimentation de l’enfant. Certes, le taux d’allaitement maternel des nourrissons âgés de 0 à 6 mois a augmenté en Afrique subsaharienne au cours de la dernière décennie, mais la moyenne régionale est de 31 %, contre 37 % dans le monde. De nombreux autres problèmes se répercutent sur l’alimentation des enfants dans la Région. Pour traiter cette question, plus de 30 des 46 États Membres de la Région africaine de l’OMS appliquent des stratégies nationales. Le présent document passe en revue ces processus de développement et de mise en oeuvre, en identifiant les obstacles et en proposant des voies d’action susceptibles de contribuer à l’amélioration de l’alimentation du nourrisson et du jeune enfant dans la Région. Une coordination efficace de toutes les institutions concernées est identifiée comme un facteur clé de succès. Le taux d’allaitement maternel des nourrissons de moins de six mois est en hausse dans la plupart des pays qui ont mis en oeuvre des stratégies ANJE. Le renforcement des capacités des agents de santé et l’évaluation des stratégies ont joué un rôle important dans cette embellie. Cependant, des écueils subsistent, notamment le financement inadéquat, une rotation élevée du personnel et des pesanteurs administratives. Il s’est également avéré difficile d’obtenir et pérenniser l’adhésion des communautés. La solution semble donc résider dans la promulgation dans le droit national du Code international de commercialisation des substituts au lait maternel, comme l’a déjà fait le Ghana. La mise en oeuvre de plans nationaux de communication et de renforcement des capacités joue également un rôle clé dans l’amélioration de l’ANJE. Relever ce défi demeure un enjeu crucial pour atteindre l’OMD 4 relatif à la mortalité infantile.
A Estratégia Global para a Alimentação dos Lactentes e das Crianças visa abordar práticas de alimentação infantil não adequadas. Embora a amamentação dos lactentes com idades até aos seis meses tenha aumentado na África Subsariana na última década, a média regional é de 31% (comparativamente com 37% a nível mundial). Inúmeros outros problemas têm impacto na alimentação das crianças na região. Para abordar esta questão, 30 dos 46 países na Região Africana da OMS estão a implementar estratégias nacionais. Este relatório analisa esse processo de desenvolvimento e implementação, identificando os desafios e propondo uma forma de melhorar as práticas de alimentação infantil na região. A coordenação eficaz de todas as agências envolvidas é identificada como um elemento chave para uma aplicação eficiente. A taxa de amamentação nos primeiros seis meses de vida dos lactentes tem melhorado na maioria dos países que implementaram as estratégias da IYCF (política nacional abrangente para a gravidez, parto e alimentação de lactentes e crianças); o reforço das capacidades dos profissionais de saúde e a avaliação das estratégias desempenharam um papel importante. No entanto, os desafios permanecem – financiamento inadequado, elevada rotação do pessoal e atrasos burocráticos. Desenvolver e manter a participação comunitária revelou-se igualmente difícil. A chave para o progresso reside na promulgação do Código Internacional de Comercialização dos Substitutos do Leite Materno na legislação nacional– conforme foi claramente demonstrado pelo Gana. A execução de planos nacionais de reforço das capacidades e comunicação desempenha também um papel fundamental na melhoria da IYCF. Abordar esta questão será fundamental para atingir o ODM 4 em termos de mortalidade infantil.
The Global Strategy for Infant and Young Child Feeding (GSIYCF) was endorsed by the World Health Assembly (WHA) in May 2002 through resolution WHA 55.25(1) and by the UNICEF Executive Board later in the same year. This strategy takes into account previous WHA resolutions, building upon past and continuing achievements particularly the Baby Friendly Hospital Initiative, the International Code of Marketing of Breast-milk Substitutes and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding. The Global Strategy for Infant and Young Child Feeding aims to address the problems of inappropriate infant feeding practices through the promotion and support of optimal feeding to assure adequate growth and development, nutritional status, health and, thus, the survival of infants and young children.
Malnutrition is a major public health problem worldwide. Globally, maternal and child under nutrition contributes to 35% of the disease burden in children younger than 5 years and is the underlying cause of 3.5 million deaths. Twenty three out of the 40 countries with child stunting prevalence of 40% or more are in Africa.(2) In sub-Saharan Africa, the proportion of infants 0–6 months who are exclusively breastfed increased by at least 20 to 50 percent over the last decade in some countries, however, the regional average is 31%, which is lower than the global average of 37%.(3) There are a number of socio-cultural practices in the region which do not support good nutrition and deprive infants of the irreplaceable protection that breast milk provides. Some examples of such practices include giving water, herbal teas and porridge to babies less than six months old.
Africa continues to face natural and man-made disasters, including civil conflicts, famine and droughts, resulting in increasing numbers of refugees and internally displaced people. Living under such precarious situations compromises the care and feeding of infants and young children. The continent bears the highest burden of the HIV pandemic. The risk of mother-to-child HIV transmission through breastfeeding has undermined the resolve of many governments in Africa to promote breastfeeding, even among unaffected families.
As part of the efforts to address the above problems, over 30 out of 46 countries in the WHO African Region have developed and are implementing their national infant and young child feeding (IYCF) strategies in accordance with the global strategy. Plans are under way to support the remaining countries in developing their national strategies.
This paper reviews the development and implementation processes for national IYCF strategies in the African Region. It also identifies the challenges encountered and proposes the way forward to improve infant and young child feeding practices in the Region.
Following the adoption of the GSIYCF by the World Health Assembly and the UNICEF Executive Board in 2002, the WHO Regional Office for Africa (WHO/AFRO) organized three separate planning meetings for 13 countries.(4) The meetings came up with a list of key activities and elements for consideration in the national strategy and developed a framework for a detailed action plan for implementation. They also identified the monitoring and evaluation tools for the national strategy.
The lessons learnt from these regional meetings led to the development of the Infant and Young Child Feeding: Guide for national implementation of the global strategy for infant and young child feeding(5) by WHO. This guide provides countries with a systematic and step-wise approach that translate the global strategy’s aim, objectives and operational targets into concrete, focused national policy, strategy and action plans. The guide was used by a number of countries in the process of developing their national strategies.
At national level the process of developing national IYCF strategy started with the assessment of the policies, programmes and practices of IYCF in countries using the WHO/LINKAGES assessment tool.(6) This process was usually carried out by two or three independent local consultants working in close collaboration with staff from the Ministry of Health. In most countries desk reviews of existing data from demography and health surveys (DHS), multi-indicator cluster surveys (MICS), recent national survey reports or studies were carried out to identify the status of various indicators. Then guidelines from the assessment tool were used to rate the country’s performance in a particular indicator. The ratings ranged from poor to very good. This information was summarized into a report. The report of the assessment was shared at a national stakeholders’ meeting and the findings formed the basis for the development of a national strategy and implementation plan.
A national IYCF strategy was derived from the assessment report and sets out priority interventions to reverse gaps identified in the situation analysis of the assessment report, such as seen in the example from Kenya.(7) The strategy has clear targets and provides a mechanism and framework for various sectors to contribute to the improvement of the health and nutritional status of children through improved infant and young child feeding practices. The strategy and implementation plans usually have a timeframe of about three years.
Implementation of National Strategies: Country Experiences
The global strategy clearly states that the primary obligation of governments is to formulate, implement, monitor and evaluate a comprehensive national policy and plan on IYCF. Adequate resources – human, financial and organizational – will have to be identified and allocated to ensure timely and successful implementation of the strategy.(8) The governments that have successfully translated the global strategy into national strategies have done so by effective national coordination to ensure full collaboration of all concerned government agencies, international organizations and other relevant stakeholders.
Currently over 30 countries(9) have developed national IYCF strategies with implementation plans. These countries are at various levels of development and implementation of their strategies. Some countries are using draft strategies and implementation plans though these are not yet finalized and published. Other countries(10)have gone through the entire process of publishing and launching their strategies and plans. These final national strategies have been widely disseminated to all key stakeholders at various levels including the provincial and district health administrations.
The national strategies form the basis for a comprehensive package and provide guidance for subsequent interventions and care in the countries. The strategies have been used as a tool for the planning and implementation of IYCF activities by all the levels of the health ministries and by partners. In some countries such as Nigeria the strategy serves as a guide for action in IYCF and a benchmark for setting annual targets.(11)
Implementation of national strategies has contributed towards improvement in the coverage of some key breastfeeding interventions such as exclusive breastfeeding rates. Figure 1 compares the under six months exclusive breastfeeding rates of selected countries before and after the development and implementation of their national IYCF strategies. Most countries significantly increased their exclusive breastfeeding rate after their strategies were developed. However, in countries such as Nigeria, Madagascar, Uganda and Zimbabwe the rates decreased after their strategies were put in place. The reasons for the decreased rates are not clear, and will require further investigations. Other related improvements include the enactment of the international code on the marketing of breast milk substitutes (Code) into national laws in Cape Verde, The Gambia and Zambia, while Kenya, Swaziland and South Africa are at the final stages of the enactment process. Implementation of the Baby Friendly Hospital Initiative (BFHI) in the context of HIV/AIDS has been revitalized in(12) countries(12) with BFHI assessment and reassessment conducted in some of these countries. Capacity building of health workers has seen exponential increases in countries with rapid cascading and expansion of training at the district level with over 6500 trainers available at national, provincial and district level to train health workers in countries.(13)
In most countries implementation was aided by the accompanying implementation plan, which clearly outlines the strategic areas, with objectives and targets as well as, when and how to reach the set targets. These strategic areas included policies and regulations; promotion of appropriate IYCF practices; IYCF in emergencies; HIV and infant feeding; partnership and coordination; capacity building; research, monitoring and evaluation; and advocacy and communication.
Commitment from ministries of health (MOH) has been crucial for successful development and implementation of the national strategy. When the MOH is in the driving seat, directing and coordinating the entire process, there is stability and sustainability to keep the process on course even if some members of the working groups change. The MOH is also able to revitalize interest and commitment among all stakeholders through active dialogue and engagement with key partners. Active involvement of key partners to support the initiatives of the MOH has kept the process on course. Countries have engaged in constructive dialogue and active collaboration with appropriate groups working for the protection, promotion and support of appropriate feeding practices. Key partners, such as WHO, UNICEF, USAID, IBFAN etc., have made technical, financial and materials support available to the MOHs. Sharing of best practices has been another facilitating factor as peers share their experiences on how they have overcome challenges in regional forums.
The process of developing and implementing national IYCF strategies has not been without challenges to countries. The process can take from an average of six months to three years, meanwhile, principal actors (within the various working groups and task forces) may change jobs or move on to other programmes; funds voted for the process may no longer be available or reduced in value due to local currency depreciation; and some key stakeholders may no longer be in the country or their focus may shift to other issues.
The major inhibiting factors include delays and the long duration of the process. This is mainly due to various bureaucratic bottlenecks. The process of getting permissions and clearance for meetings, documents and approval can be unduly lengthy (between six weeks and three months); in the meantime there are other competing activities of equal importance in which the same people are expected to participate.
Where IYCF issues are not prominent or high on the political and development agenda, such as featuring in national development plans and strategies, and only seen as a health issue, the lack of high political stimulus needed to drive implementation of a national strategy is an issue.
The absence of a comprehensive national communication and social marketing strategy makes advocacy and sensitization of policy makers at all levels and the general public challenging. The lack of data driven advocacy messages leads to ineffective communication to the target population.
Establishing and sustaining the involvement of the community, especially the motivation of volunteers among mother support groups and failing to deal with some cultural norms concerning the role of mother-in laws, grandmothers and fathers can make grassroots implementation difficult.(14) The lack of a comprehensive national capacity building plan which addresses in-service, pre-service and community workers’ training is a hindrance.
Counselling skills are crucial in IYCF support yet these are often not taught in nursing and medical schools. Bridging this knowledge and skill gaps has not always been easy. The high attrition rate of health workers means that trained and competent health workers are constantly in short supply. Trained health workers get attracted to places and programmes with better salaries; such a scenario can sometimes make a well thought out implementation plan unachievable.
IYCF makes a huge contribution towards child survival; about 19% of under five mortality can be prevented if there is universal coverage of breastfeeding and complementary feeding(15). However, the size of budget allocations that both governments and partners commit to child survival in general and IYCF in particular is disproportionately low and unrealistic. This is one of the major challenges most countries encountered achieving the goals of their national IYCF strategies.
The enactment of the International Code of Marketing of Breast-milk Substitutes into national law is an important step forward. The existence of a well informed and motivated government agency responsible for the laws and policies on the marketing breast-milk substitutes such as (the Food and Drugs Board in Ghana and the National Agency for Food and Drug Administration and Control in Nigeria) and an oversight committee that ensure the enforcement of the law is important. Dynamic leadership in the government ministries (Ministry of Health, Labour and Employment, Justice etc.) is instrumental to the enactment and enforcement of laws on the Code and maternity protection for working mothers and child rights etc. Development partners, particularly UN agencies such as ILO, WHO and UNICEF, should continue to serve as powerful advocates and provide technical support to governments for the realization of key policy and legislation in favour of child survival including putting IYCF programmes high on the political and developmental agenda.
The activities of socio-cultural structures existing in communities – NGOs, community based organizations (CBOs), traditional leadership groups – need to be harnessed for advocacy and social mobilization for IYCF.Technical and financial support of development partners should be invested in the skills of locally available human resources to ensure availability and sustainability of competent people in the communities.
There is a need to develop:
- A comprehensive national communication and social marketing strategy which uses data driven advocacy messages to create awareness and behavioural change among the target audience.
- Comprehensive national capacity building plans which include equipping training institutions to facilitate capacity development in IYCF at pre-service and in-service levels.
- Counselling in all areas dealing with IYCF at every contact point with mother and child.
To reduce the long development process period, efforts to remove bureaucratic bottlenecks need to be intensified by ensuring that advance preparations for activities are done and communication among the various stakeholders is good.
Financial allocation to IYCF activities should be proportionate to the burden of disease and the deaths that could be averted by improved breastfeeding and complementary feeding practices. District health management teams should develop need-based plans and budgets for child survival and appropriately fund IYCF activities based on the contribution of IYCF towards child survival in their respective districts.
WHO, in collaboration with other partners, should intensify advocacy to countries without national strategies to develop one, while continuing to provide technical support to countries to scale up the implementation of their strategies. The year 2012 will be ten years since the adoption of the global strategy and an opportune time to conduct a comprehensive multi-country evaluation to assess the effects of the strategy on the support, promotion and protection of appropriate IYCF as well as its contribution to reducing child morbidity and mortality.
Promotion, protection and support for IYCF in general and breastfeeding in particular has been going on actively since the early 1990s; a lot of the activities were done by different and many parties without much coordination. However, the introduction of the Global Strategy on IYCF revitalized enthusiasm, national strategies emphasized the strong coordination role of the MOH and the roles and responsibilities of government, NGOs, UN agencies and other partners were clearly stated. National strategies are data driven, more focused on specific country needs and involve key stakeholders ensuring ownership and sustainability.
The development and implementation of national strategies has not been without challenges. Overcoming the challenges identified will require concerted efforts from government, partners and the community to eventually ensure that IYCF practices are taken to scale to make a meaningful contribution towards child survival and the attainment of Millennium Development Goal 4.
- WHO, Global Strategy for Infant and Young Child Feeding. WHO, 2003.
- Black RE, Allen L, Bhutta Z, Caulfield L, de Onis M, Ezzati M, Mathers C, Rivera J. Maternal and child under nutrition: global and regional exposures and health consequences. The Lancet. 2008; 371: 243–260.
- UNICEF. State of World’s Children 2010.
- Angola, Botswana, Burkina Faso, Cape Verde, Côte d’Ivoire, Ethiopia, Ghana, Guinea Bissau, Mali, Mozambique, Sao Tome and Principe, Senegal and Zimbabwe,
- WHO, Infant and Young Child Feeding: Guide for national implementation of the global strategy for infant and young child feeding. WHO, 2004.
- WHO/Linkages. Infant and Young Child Feeding: A tool for assessing national practices, policies and programmes. WHO, 2003.
- MOPHS/WHO/UNICEF. Kenya National Strategy on Infant and Young Child Feeding. WHO, 2008.
- WHO. Global Strategy for Infant and Young Child Feeding. WHO, 2003.
- Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroun, Cape Verde, Côte d’Ivoire, DRC, Ethiopia, Gabon, Ghana, Gambia, Guinea Bissau, Lesotho, Kenya, Mali, Malawi, Mozambique, Nigeria, Niger, Sao Tome and Principe, Rwanda, South Africa, Swaziland, United Republic of Tanzania, Togo, Uganda, Zambia and Zimbabwe.
- Ethiopia, Ghana, Gambia, Lesotho, Kenya, Malawi, Nigeria, Senegal, Sierra Leone, United Republic of Tanzania, Uganda, Zambia and Zimbabwe.
- Federal Ministry of Health, Nigeria. National Policy on Infant and Young Child Feeding in Nigeria. Federal Ministry of Health, Nutrition Division, Abuja, 2005.
- Botswana, Lesotho, Madagascar, Malawi, Namibia, South Africa, Swaziland, United Republic of Tanzania, Uganda, Zambia, Zimbabwe.
- WHO. Division of Family and Reproductive Health; 2006 – 2007 at a Glance. WHO Regional Office for Africa, 2007.
- Holmes WR, Savage F. Exclusive breastfeeding and HIV. The Lancet. 2007; 369: 1065–1066.
- Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? The Lancet. 2003; 362: 65–71.