Perspective: What Will It Cost to Scale-up Breastfeeding Programs? A Comparison of Current Global Costing Methodologies

Abstract

Breastfeeding is one of the most feasible and cost-effective maternal-child health interventions. Currently, global investments needed to achieve the WHO global nutrition target for exclusive breastfeeding (EBF) do not meet the recommended standards for economic investment and implementation of policies supporting mothers to breastfeed. Estimating implementation costs of high-quality, high-impact programs based on each country's enabling environment and specific context is essential for developing and prioritizing recommendations that can drive the successful scaling-up of breastfeeding programs globally. We provide a detailed comparison (strengths, limitations, and gaps) of the 2 most recent global cost analysis frameworks used to estimate financial needs for scaling-up breastfeeding interventions from World Breastfeeding Costing Initiative (WBCi) and the World Bank. Our comparison found that the World Bank presents the more advanced costing methodology for scaling-up breastfeeding programs. However, there is a need to adapt and improve this costing framework to guide individual countries based on key contextual factors that consider the complexity of health systems.

Introduction

Breastfeeding has well-established health benefits for infants and mothers (1–3). However, exclusive breastfeeding (EBF) prevalence remains low globally at 40% (4). In 2012, the World Health Assembly (WHA) set a global target to increase the rate of EBF in the first 6 mo to ≥50% by 2025 (5). Studies tracking progress of breastfeeding policies and programs have shown current investment levels are insufficient to drive the degree of progress that is needed to meet the global target (3, 6–8). As a result, countries are losing millions of dollars in excess health care costs and loss of productivity every year owing to suboptimal breastfeeding practices (9–11).

Reaching the EBF global nutrition target will require political support reflected in an increase in multisectoral investments from governmental and nongovernmental organizations to enable breastfeeding environments (3, 4, 8). Promoting, protecting, and supporting breastfeeding requires removing structural and societal barriers that interfere with women's ability to breastfeed optimally (2). When there are adequate investments towards high-quality breastfeeding interventions, breastfeeding practices can improve rapidly (3, 8). Examples of high-impact, cost-effective breastfeeding policies and interventions are paid maternity leave, workplace breastfeeding protection policies, the International Code of Marketing of Breast-milk Substitutes (Code), infant and young child feeding (IYCF) counseling, the Baby-Friendly Hospital Initiative (BFHI), and media campaigns (3, 12). However, there are limited data on the implementation costs of breastfeeding interventions to inform decision makers (3, 6, 7).

Estimating the financial needs to enable the breastfeeding environment can help foster evidence-based advocacy to strengthen political and financial commitments for breastfeeding (2, 3, 13). Previous studies have estimated the costs for scaling-up packages of nutrition interventions (14, 15) and suboptimal breastfeeding practices (i.e., costs of not breastfeeding) (9–11). However, studies have not offered a standard costing approach at country level for implementing packages of interventions that specifically promote, protect, and support breastfeeding to help government and nongovernmental decision makers budget the financial support needed to effectively scale-up programs seeking to improve breastfeeding (13, 16).

The Becoming Breastfeeding Friendly (BBF) guide tracks countries’ readiness for and progress with scaling-up breastfeeding programs, with the ultimate goal of promoting the effective scale-up and sustainability of breastfeeding programs globally. BBF is designed to help countries identify specific implementation gaps while taking into account key elements that need to be in place to create an enabling breastfeeding environment (17). These key elements are grounded in the complex adaptive systems (CAS) Breastfeeding Gear Model (BFGM) (18). CAS posits that interactions among system components are complex, nonlinear, and need to consider the uniqueness of local context to optimize the pathways for scaling-up (19). BBF works with partner countries to estimate the costs of high-quality, high-impact, scalable interventions based on each country's readiness, specific needs, and interests (17). These cost estimates are needed to inform and empower decision makers on financial data–driven decisions to successfully improve breastfeeding outcomes (17).

As there is currently a lack of clear country-level guidance for estimating costs to scale-up breastfeeding programs to create an enabling breastfeeding environment, global costing frameworks can serve as resources for countries implementing national comprehensive breastfeeding strategies. These frameworks are helpful for approximating finances, raising awareness, and highlighting the importance of additional financial resources (20). However, global frameworks have not been widely adopted at country level because they are relatively recent, have varying methods, can be difficult to translate into practice, do not capture local contexts and priorities, and nationally representative data for conducting these cost analyses can be limited or unavailable (20). Therefore, the specific aims of this perspective are to: 1) describe the 2 most recent global costing analyses for scaling-up inventions to enable breastfeeding environments; 2) provide a methodological comparison to identify strengths, limitations, and research gaps; and 3) discuss implications and recommendations for applying existing global costing frameworks to analyses at country level.

Methods

We searched for articles in PubMed, Global Health, and Scopus to identify the 2 most recent global cost analyses for implementing breastfeeding programs published as of September 2017. The following components of the costing studies were systematically extracted in order to compare costing methods: study objective, target audience, rationale of included interventions, grouping of interventions, existing and desired level of program coverage, country and cohort samples used in the analysis, data sources for unit costs, and methods used to calculate the total financial need and cost per child. We conducted an in-depth analysis of each methodology and compared their strengths and weaknesses in the context of country-level analyses.

Description of costing studies

We present cost analyses by Holla-Bhar et al. (21) and Shekar et al. (22), which will be referred to as the World Breastfeeding Costing Initiative (WBCi) (21) and World Bank costing frameworks (22), respectively. We describe information from both studies relevant to the aims of this paper (Table 1).

TABLE 1.

Overview of WBCi and World Bank global cost analyses¹

Components of costing studies	WBCi (21)	World Bank (22)
Objective and target audience
Study objective	To estimate the financial needs and detailed cost estimates needed to fully implement intervention in the Global Strategy for IYCF2	To estimate the additional3 financing needs based on existing levels of coverage of key interventions to achieve the WHA global nutrition target of 50% EBF by 2025
Target audience	Governments to support the implementation of the Global Strategy for IYCF	Governments, official development assistance, and other stakeholders to prioritize breastfeeding investments
Rationale and grouping of interventions
Rationale for included interventions	Policies and interventions in the Global Strategy for IYCF to create an enabling environment for women to achieve optimal breastfeeding	Core set of nutrition-specific interventions, which have proven to be efficacious in enhancing breastfeeding, that can be implemented in a comprehensive strategy to create an enabling environment for EBF up to 6 mo. The effect of maternity leave cash benefits on breastfeeding is limited and presented as an extension to the nutrition-specific package4
Grouping of included interventions	One-time costs 1) IYCF policy development and review for implementing the Global Strategy for IYCF 2) Drafting national legislation and legislative process for the Code	Package of nutrition-specific interventions 1) Probreastfeeding social policies, legislation, monitoring and enforcement of the Code, BFHI, and maternity protection/leave 2) National breastfeeding promotion campaigns 3) Infant and young child nutrition individual or group-based counseling
	Annual (recurrent) costs 3) BFHI implementation 4) Training of health workers 5) Community support for breastfeeding 6) Media promotion 7) Training on the Code 8) Monitoring the Code, BFHI, and community support 9) Maternity entitlements for 6 mo	Extension to nutrition-specific package 4) Maternity leave cash benefits for 6 mo
Program coverage and time frame
Existing level of program coverage	Not clear if factored into the analysis5	Factored into the analysis
Desired level of program coverage	100% program coverage6	100% program coverage
Time frame to achieve desired level of program coverage	Not specified7	10 y
		– 5-y scale-up phase from current level of intervention coverage
		– 5-y maintenance phase
Costing approach to calculate the total financial need
Countries in analysis	194 developing countries	27 low- and middle-income countries
Extrapolating results to achieve global cost estimate	Findings were extrapolated to cover 214 developing countries and territories. No methods were applied to cover additional 20 countries and territories. There is no difference between the cost estimate for 194 countries included in the analysis and the cost estimate reported to cover 214 countries and territories	Findings were extrapolated to all low- and middle-income countries.8 A multiplier of 1.28 was applied to the sample cost to achieve the total financial need9
Calculating the financial need	FNi = UC × Pop10	FNi,y = UC × Popy × ICy
	Financial need (FN) estimates for an intervention (i) were calculated by multiplying the unit costs10 (UC) by the target population (Pop)11	Additional3 financial need (FN) estimates for an intervention (i) in a given year (y) were calculated by multiplying the unit costs11 (UC) by the target population (Pop)12 in the year (y) and incremental13 coverage (IC) assumed for the year (y)
	The FNi for each intervention was totaled to achieve the total financial need (FNT) for implementing the Global Strategy for IYCF	The FNi,y for each intervention for each year was subtotaled. An additional 11% was applied to the subtotal to cover implementation costs, where 9% was for capacity strengthening and 2% was for monitoring and evaluation. Finally, the multiplier (1.28) was applied to cover all low- and middle-income countries to achieve the total financial need (FNT) for achieving the WHA target over years
Total financial need14	$17.6 billion to implement Global Strategy for IYCF	$29.8 billion additional costs3 over 10 y to achieve the WHA global nutrition target15
	– $485 million one-time cost– $17.1 billion annual (recurring) costs	– $5.7 billion additional costs3 for the package of nutrition-specific interventions over 10 y (range over 10 y: $136 million–$753 million per year)
		– $24.1 billion additional costs3 for the extension of maternity leave cash benefits over 10 y (range over 10 y: not reported)
Costing approach to calculate cost per child
Cohort to calculate cost per child16	135 million live births, over 1 y– Based on SOWC in 2013	1.2 billion 0–11 mo-old children, over 10 y– Based on UN World Population Prospects
Formula to calculate cost per child17	1) Cost per child = FNi/Pop 2) Cost per child = FNT/Pop	Cost per child = FNT/Pop
	Cost per child estimates were calculated for 1) the financial need for each intervention (FNi) and 2) the total financial need (FNT). Both FNs were divided by the number of live births (Pop) from 1 y	Cost per child estimates were calculated by dividing the total financial need (FNT) for nutrition-specific interventions by the number of 0–11 mo-old children, over 10 y (Pop). Cost per child estimates were not calculated for each intervention (FNi)
Cost per child	$130 per live birth in a year to implement Global Strategy for IYCF7,18– $3.60 per live birth in a year, one-time cost7	– $4.70 per child born within the 10-y period to implement package of nutrition-specific interventions
	– $127 per live birth in a year, recurring costs7	– Cost per child for the extension of maternity leave cash benefits was not reported

¹BFHI, Baby-Friendly Hospital Initiative; Code, International Code of Marketing of Breast-milk Substitutes; EBF, exclusive breastfeeding; IYCF, infant and young child feeding; SOWC, State of the World's Children; WBCi, World Breastfeeding Costing Initiative; WHA, World Health Assembly.

²Target rates for optimal breastfeeding practices (i.e., early initiation, EBF, continued breastfeeding) after programs were implemented were not specified by WBCi.

³“Additional” is defined by the World Bank as the additional financial needs (i.e., costs) based on current level of program coverage, not current level of spending.

⁴Maternity leave is associated with an increase in EBF, but the effect is not specific to maternity leave cash benefits (12).

⁵Unclear based on methods and results if existing levels of program coverage were factored into the WBCi analysis.

⁶WBCi stated “full implementation” of programs and policies in Global Strategy for IYCF, we assumed this was 100% program coverage.

⁷WBCi did not specify a time frame to fully implement interventions, we assumed they intended full implementation would occur within 1 y to draw comparisons for the cost per child estimates.

⁸The World Bank did not report the number of countries and which countries the analysis applied to after the sample cost was extrapolated to achieve the global cost estimate.

⁹Multiplier was derived by dividing 1 (100% implementation coverage) by 0.78 (78% of the global burden of non-EBF in 27 low- and middle-income countries); 1/0.78 = 1.28.

¹⁰Financial need formula was not presented by WBCi, we adapted the presented formula based on the study's written methods.

¹¹Interventions can have ≥1 unit costs.

¹²For WBCi the target population (Pop) was the country, the global birth cohort, or women living below the poverty line; for the World Bank the target population (Pop) was the general population (i.e., country) or mothers of children age 0–11 mo.

¹³“Incremental” is defined by the World Bank as the difference (%) in population coverage from one year to the next for this analysis, not additional costs from one year to the next.

¹⁴Costs were converted to US dollars ($) and unit costs were inflated to 2012 values in WBCi and 2015 values in World Bank.

¹⁵The World Bank reported the total financial need of the nutrition-specific package and extension of maternity leave together; for the purposes of the methodological comparison in this study we added the 2 costs together ($5.7 billion + $24.1 billion = $29.8 billion) to estimate the total financial need for all interventions included in the analysis.

¹⁶Cohorts used to calculate cost per child were defined differently between studies: for WBCi, number of live births in 1 y; and for the World Bank, number of 0–11 mo-old children within a 10-y period.

¹⁷Cost per child formula was not presented by WBCi or the World Bank; we adapted the presented formula based on the studies’ written methods.

¹⁸Cost per child for each intervention is presented in this study; we present only the total, one-time, and recurring costs.

WBCi: implementing the Global Strategy for Infant and Young Child Feeding

Objective and target audience

WBCi was launched by International Baby Food Action Network (IBFAN) Asia and Breastfeeding Promotion Network of India (BPNI) in 2013. The objective of the WBCi analysis was to estimate the cost of fully implementing interventions from the WHO and UNICEF Global Strategy for Infant and Young Child Feeding (Global Strategy for IYCF) (21). The aim of the Global Strategy for IYCF is to improve the nutritional status, growth and development, health, and survival of infants and young children through optimal feeding (23). This cost analysis was conducted to address deficits in financial information needed to encourage governments to facilitate an enabling environment for breastfeeding by supporting the implementation of the Global Strategy for IYCF to improve optimal breastfeeding practices (21).

Rationale and grouping of interventions

The Global Strategy for IYCF included programs to facilitate enabling environments for women to achieve optimal breastfeeding (i.e., early initiation, EBF, continued breastfeeding) (23). Cost estimates for policies and interventions in the Global Strategy for IYCF were grouped by one-time and annual (recurrent) costs (21).

Coverage and time frame

Existing levels of program coverage for all the included interventions were not clearly described in the methods or reflected in the results, therefore, it is unclear if this was factored into the analysis. A time frame to fully implement the Global Strategy for IYCF was not specified for this analysis. For the methodological comparison, we assumed that WBCi expected full implementation to occur within 1 y.

Costing approach to calculate total financial need

Data from 194 countries were included in the analysis to calculate the total financial need (24). Findings were extrapolated to cover 214 countries and territories (21). The WBCi authors reported that the missing data from 20 countries and territories were unlikely to significantly affect the cost estimates (21). There is no difference between the cost estimate for 194 countries included in the analysis and the cost estimate reported to cover 214 countries and territories.

To calculate the total financial need for fully implementing the Global Strategy for IYCF, the financial need for each intervention was calculated by multiplying the unit costs by the number of units (e.g., countries, mothers, or children) in the target population. A program experience approach was used where unit costs were based on data from existing programs or median costs budgeted by countries. Unit costs were adjusted for inflation to 2012 values (25) and converted into US dollars (21). A distinct approach was used to estimate maternity entitlements, which was calculated by allocating $2/d per woman living below the poverty line set by the World Bank for 6 mo (i.e., number of households living under the poverty line as estimated by the State of the World's Children (SOWC)) (21, 24). WBCi assumed that this amount would offset the economic costs to the mother and her family to enable mothers to stay in necessary proximity to their newborns for EBF (21). The target population was dependent on the intervention (e.g., for maternity entitlement, the target population was the women living below the poverty line) (21, 24). Finally, the financial need for each intervention was totaled to achieve the total financial need for implementing the Global Strategy for IYCF. Overhead (e.g., administrative salaries) and capital infrastructure (e.g., delivery systems) costs were excluded from the total estimate because these can differ widely among countries. WBCi assumed countries would have basic delivery capacity (21). The training of community-based or volunteer support groups was estimated but the operational costs for developing, maintaining, and expanding breastfeeding support groups were not (21).

Costing approach to estimate cost per child

Cost per child was estimated for each intervention and the total financial need for implementing the Global Strategy for IYCF. The cost per child was estimated by dividing the cost of the intervention or total financial need by the global birth cohort (21). The global birth cohort was the number of live births in 2013 from 194 countries (21, 24). We assumed the cost per child was per year.

Results of the WBCi cost analysis

The total financial need for implementing the Global Strategy for IYCF in 214 countries and territories was estimated at $17.5 billion, or ∼$130 per live birth per year; one-time costs were $485 million and annual (recurrent) costs were $17.1 billion (21).

World Bank: additional costs needed to achieve the WHA global nutrition target for EBF

Objective and target audience

The World Bank in partnership with Results for Development Institute (R4D) and 1000 days aimed to estimate costs and impacts on 4 out of 6 of the WHA global nutrition targets (stunting, anemia, EBF, and wasting). Low birth weight and overweight were not included owing to insufficient data on the prevalence of the condition or lack of consensus on effective interventions to achieve the goal (22). For the purpose of this paper we only present the methods used for cost analysis to estimate the additional financing needed to achieve the WHA global nutrition target of 50% EBF by 2025. The additional financial needs were based on existing levels of coverage of key interventions to create an enabling environment for breastfeeding (22). The results from this study were intended to inform the prioritization of investments by governments, official development assistance, and other stakeholders.

Rationale and grouping of interventions

The World Bank estimated a core set of nutrition-specific interventions, which have proven to be effective in improving breastfeeding rates and can be implemented in a comprehensive strategy to create an enabling environment (12, 26). The package of nutrition-specific interventions included IYCF individual or group counseling; national breastfeeding promotion campaigns; and probreastfeeding social policies. Probreastfeeding social policies included legislation, and monitoring and enforcement of policies related to the Code, BFHI, and maternity protection and leave. The financial pattern for maternity leave cash benefits differed from the nutrition-specific package interventions (12, 26). Studies have shown maternity leave cash benefits may increase breastfeeding rates, but this intervention also generates other social, health, and developmental benefits (12, 26). Because the direct effect on breastfeeding outcomes is limited, maternity leave cash benefits are presented as an extension to the nutrition-specific package (22).

Program coverage and time frame

Based on existing levels of coverage for each intervention, a linear scale-up was assumed to increase at a constant rate over 5 y to full coverage with a 5-y maintenance phase at full coverage (22). This was the assumed pace of scale-up for the EBF target because interventions overlapped with the stunting target. For stunting, interventions are delivered throughout the first 5 y of life. Therefore, a 5-y scale-up scenario was used to allow for the cohort of newborns to accrue the benefits for the stunting interventions (22). Keeping the same pace of scale-up would allow for easier aggregation and calculation of financial needs for a multitarget comprehensive intervention package (22).

Costing approach to estimate the total financial need

The World Bank factored in existing levels of program coverage to estimate the additional financial needs to achieve 100% intervention coverage to create an enabling environment to achieve a rate of 50% for EBF (22). Estimating the existing levels of coverage was based on the Lives Saved Tool (LiST) for breastfeeding counseling (27), and qualitative evidence of full or partial implementation for the Code (28) and maternity leave policies (29). For maternity leave cash benefits, the coverage was estimated as the product of the female labor force participation rate and the International Labour Organization (ILO) coverage in practice (i.e., number of people who have the right to receive benefits but are not necessarily current beneficiaries) in each country (22). The levels of coverage for national breastfeeding promotion campaigns and probreastfeeding social policies for the BFHI were not reported.

Twenty-seven low- and middle-income countries were included in the analysis, 20 with the highest burden of children under 6 mo of age who were not exclusively breastfed and 7 with <10% rate of EBF (22). The sample was limited to low- and middle-income countries because they have the highest concentration of undernutrition (22). Information on cost, coverage, and delivery modalities is not comparable or not readily accessible in high-income countries (22). This sample captured 78% of the global burden of children under 6 mo of age who were not exclusively breastfed and a multiplier (1.28) was used to extrapolate the sample cost to all low- and middle-income countries (22).

To calculate the total financing needs to achieve the EBF target, the financial need for each program for each year was calculated. The financial need for an intervention was calculated by multiplying the unit cost(s) for an intervention by the target population by the incremental coverage assumed for the given year. A program experience approach was used to estimate unit costs, which were based on the financial needs of programs. Unit costs were adjusted for inflation to 2015 values and converted into US dollars (22). The extension of maternity leave cash benefits was estimated from the current duration of paid leave to 6 mo at a rate of 67% of the minimum wage level in each country for women working in the formal sector (29). The target population was the general population for probreastfeeding social policies and national breastfeeding promotion campaigns. The target population was mothers of children age 0–11 mo for IYCF individual or group-based counseling and maternity leave cash benefits. The existing levels of program coverage were determined to apply the incremental coverage assumed for each year over 10 y. Incremental is defined here as the difference (%) in population coverage for an intervention from one year to the next (22). The financial need for each intervention for each year was subtotaled and an additional 11% was applied to the subtotal to cover implementation costs, where 9% was for capacity strengthening and 2% for monitoring and evaluation (22). The additional cost was applied to all low- and middle-income countries to generate the total financial need for achieving the WHA target over 10 y.

Costing approach to estimate cost per child

The cost per child was estimated only for the total financial need for implementing the package of nutrition-specific interventions. This was estimated by dividing total financial need by the total number of 0–11 mo-old children projected over a 10-y period (2016–2025), which was about 1.2 billion 0–11 mo-old children over 10 y (i.e., ∼120 million 0–11 mo-old children each year) (22).

Results of the World Bank cost analysis

The estimated additional financing needed over 10 y to scale-up a core set of nutrition-specific interventions across all low- and middle-income countries to achieve the target for EBF was $5.7 billion total, or ∼$4.70 for every newborn within the 10-y period (22). The extension of maternity leave cash benefits to 6 mo for all working women in the formal sector was estimated to cost an additional $24.1 billion over 10 y (22).

Methodological comparison

The 2 cost analyses compared in this article resulted in 2 very different global cost estimates for creating an enabling breastfeeding environment. This is largely attributed to differences between the aims, the target populations in each study, and the time frames for implementing or scaling-up interventions (Table 1). The WBCi costing framework helps decision makers understand the one-time and recurring costs for fully implementing a specific strategy (21), such as the Global Strategy for IYCF (23). By contrast, the World Bank framework helps decision makers understand the costs to increase coverage of interventions over a period of time to achieve a specific breastfeeding outcome (22), such as the WHA EBF global nutrition target (5).

The time frame to achieve the desired level of program coverage for the target population was a notable methodological difference between studies. The World Bank analysis considered a scale-up phase and a maintenance phase based on existing levels of program coverage until a desired level of coverage was reached over 10 y whereas WBCi did not include such a costing component. The WBCi analysis would be strengthened by clearly describing how existing levels of program coverage for each intervention can be considered in the analysis. The WBCi analysis could also be improved if it considered a specific time frame for scaling-up interventions because this component of the analysis could help further inform decision makers. When considering a time frame for the WBCi analysis, it should be acknowledged that this study aimed to improve optimal breastfeeding practices (i.e., early initiation, EBF for 6 mo, and continued breastfeeding up to 2 y or beyond) whereas the World Bank only targeted EBF. If WBCi were to include a specific time frame in their analysis, it would be for implementing the Global Strategy for IYCF programs that included policies and programs for a broader target population of children up to 2 y, whereas the World Bank included policies and interventions to improve EBF up to 6 mo. Only costing EBF interventions for children ages 0–6 mo, as done by the World Bank, is appropriate to focus on given the strong priority being placed on EBF by the WHA global target.

A notable difference between the studies was that WBCi considered one-time and annual costs whereas the World Bank did not. The World Bank analysis could be improved if one-time and annual costs were considered for implementing, monitoring, and, in some cases, enforcing interventions (e.g., policy making for the Code is a one-time cost, monitoring and enforcing the Code is a recurrent cost). Both costing frameworks could be improved if start-up costs were considered in relation to post start-up costs (30). Considering these cost differences across time would help decision makers better understand initial and long-term financial needs for implementing breastfeeding interventions (30).

The studies considered cost differences between countries’ income level differently. As noted in the World Bank study, the data to conduct cost analyses in many high-income countries are lacking and not comparable to low- and middle-income countries (22). Therefore, high-income countries were not included in the World Bank study. WBCi did not exclude high-income countries but their estimates were not adjusted for implementing interventions at different country income levels. Both analyses could be improved if cost estimates were calculated or adjusted for the costs of scaling-up breastfeeding programs in high-income countries because there is a need to improve breastfeeding outcomes in these countries as well (2, 4).

Both studies aimed to achieve full coverage for interventions to facilitate an enabling environment for women to breastfeed, but the interventions included and how they were defined were different between studies. WBCi described a more comprehensive set of interventions to achieve optimal breastfeeding practices (21). The World Bank grouped multiple policies under the cost estimate for probreastfeeding social policies, which included the cost estimates for legislation, monitoring, and enforcement of the Code, BFHI, and maternity protection and leave (22). If data are available, it would be more informative to separate these costs. Also, it was unclear in the World Bank analysis if “maternity protection” included maternity workplace policies based on the World Bank's description of the intervention. A recent UNICEF report interpreted that the World Bank did not include maternity workplace interventions in their analyses (31), and WBCi excluded this intervention as well. Investing in maternity workplace policies is essential for protecting and supporting breastfeeding mothers and effective in improving breastfeeding outcomes (2, 12, 31). The World Bank analysis also did not include community-support interventions (i.e., strengthening connections between health facilities and communities) whereas WBCi did; these are important for supporting breastfeeding mothers, especially in settings where health systems are weak (2, 31).

Both studies were limited by available data for estimating the costs of maternity benefits and their approaches for estimating these costs were notably different. Both acknowledged the cost estimates were highly variable between countries owing to salary considerations and differences for women working in the formal compared with the informal sector (i.e., amount and sources of funding). WBCi calculated a daily allowance ($2/d for 180 d) for women living below the poverty line and did not compute the costs of maternity benefits for women working in the formal and informal sectors (21). The World Bank only calculated maternity leave cash benefits to cover the formal labor sector (22). Further research is needed to estimate the costs of extending paid maternity leave to the informal sector, especially in low- and middle-income countries, and its effect on EBF (21, 22). Extending coverage to this vulnerable population is likely to be essential for improving breastfeeding and health outcomes (12, 31).

There are important considerations to make when comparing the samples used in each costing method to compute the cost per child estimates. First, both were achieved by taking the total financial need and dividing it by the number of children in the cohort. WBCi's total financial need was for implementing the Global Strategy for IYCF with one-time and recurring costs over an unspecified period of time over the number of live births from 2013 ($17.6 billion/135 million live births from 2013 = $130 per live birth per year to implement the Global Strategy for IYCF) (21). The World Bank's costs were estimated for the additional financial need to achieve the WHA target for EBF in 10 y over the projected population of 0–11-mo-old children in low- and middle-income countries ($5.7 billion/1.2 billion of 0–11-mo-old children = $4.70 is the additional need per child born within the 10-y period to achieve the WHA target) (22). The cohort of children 0–11-mo old underestimates the cost per child given that EBF interventions only cover children 0–6 mo of age. The World Bank cost per child estimate was also not adjusted for children not covered during the 5-y scaling up phase and for children covered at baseline. It is important to interpret these results carefully because language is used interchangeably and both of these estimates are not exact unit costs but can serve as tools for advocacy.

Discussion

Our findings suggest that the World Bank costing methodology is more appropriate for estimating the financial needs for scaling-up breastfeeding programs to create an enabling breastfeeding environment at a country level. If the objective of a cost analysis is to estimate implementation costs, the WBCi methodology provides more specific guidance on estimating one-time and recurrent unit costs for breastfeeding interventions. Both costing methodologies can inform decision makers to garner support for breastfeeding initiatives. However, a major strength of the World Bank analysis was including costing components with a time frame to implement interventions that considered cost differences in the scale-up and maintenance phases based on the incremental differences in program coverage between years.

Global costing analyses, such as those developed by WBCi and the World Bank, provide frameworks for estimating costs of breastfeeding interventions. The results can potentially help improve national development by making informed recommendations and policies that support implementation efforts. However, both global methodologies produce broad financial approximations for implementing programs at a global level and are limited when it comes to estimating the true costs at country level. Further development in cost analysis frameworks tailored to country-specific gaps is needed to set standards for economic investment, to guide the implementation of policies and interventions supporting mothers, and ultimately to meet global nutrition targets for breastfeeding. Once costing methods have been improved, more research will be needed for estimating the return on investment by sector from different perspectives (e.g., mothers, society, diverse government sectors).

Implications and recommendations for cost analyses at country level

Global cost frameworks need to be adapted to address country-specific contexts. At a country level, cost analyses can be tailored to countries’ needs while considering the countries’ environment for scaling-up breastfeeding interventions (20). Countries’ costing estimates should include covering the costs of the iterative nature of adapting and testing the breastfeeding interventions in the setting where they will be operating (32). Estimates at a country level for scaling-up breastfeeding interventions will require moving from linear to CAS frameworks (19). The use of evidence-based comprehensive metrics designed to assess the breastfeeding enabling environment at the country level, such as BBF (17), can help identify and prioritize breastfeeding policies and interventions that need to be costed out to facilitate the decision-making process.

Effectively scaling-up breastfeeding interventions must consider the pathways for increasing and sustaining coverage of effective interventions. Therefore, we propose 6 considerations for estimating costs at the country level. First, estimates should be based on the context where interventions are implemented (e.g., national, subnational, or local level; urban compared with rural areas) and include representative data sources (e.g., census data for analyses conducted at a national level) (17, 33). Second, analyses should consider the country's implementation strategy (i.e., investing in programs for improving just EBF or all optimal breastfeeding practices). Third, country estimates should also consider the current level of investment (i.e., budget and spending) from public sectors and private donors for promoting, protecting, and supporting breastfeeding and how much more funding will be needed to increase program coverage to improve the breastfeeding rate. Fourth, country estimates should factor in existing health programs, routine health contacts, and delivery platforms (e.g., routine postnatal care, peer-to-peer counseling, local health clinics). Fifth, assumptions for unit costs and time frames for scaling-up interventions should be based on a country's readiness to scale-up breastfeeding interventions, current legislation, and recommended actions needed to achieve specific targets (e.g., extending maternity leave from 14 to 16 wk over 2 y). Sixth, estimates should include specific target populations for each intervention (i.e., costs for children, mothers, or the general population) and indicators for desired outcomes (i.e., rates of early initiation, EBF, and/or continued breastfeeding) based on existing levels of coverage.

To maximize the utility of findings for decision making, cost estimations should compute the total financial need for priority interventions as incremental costs per child (i.e., above and beyond what countries are already investing in health, social protection, and education) because this can serve as a powerful advocacy tool for relatively small increases in financial investments from public sectors and private donors (1, 2, 6). Countries need to be aware and consider how estimates could change with updates of existing guidelines and recommendations for breastfeeding interventions (e.g., new WHO/UNICEF revisions to the BFHI). Further development methodology for estimating the costs for scaling-up breastfeeding interventions should better reflect the dynamic models needed to inform financial decisions in the breastfeeding domain.

Conclusion

Breastfeeding promotion, protection, and support need sustainable multisectoral investments to achieve the EBF global nutrition target and improve the health of children and mothers. The World Bank costing methodology is, to the best of our knowledge, currently the most comprehensive framework for estimating the financial needs to scale-up breastfeeding programs to create an enabling environment for EBF. Countries should consider adapting this framework to estimate the scale-up costs of breastfeeding interventions at the country level to inform decision makers.

Notes

Perspective articles allow authors to take a position on a topic of current major importance or controversy in the field of nutrition. As such, these articles could include statements based on author opinions or point of view. Opinions expressed in Perspective articles are those of the author and are not attributable to the funder(s) or the sponsor(s) or the publisher, Editor, or Editorial Board of Advances in Nutrition. Individuals with different positions on the topic of a Perspective are invited to submit their comments in the form of a Perspectives article or in a Letter to the Editor.

Supported by the Family Larsson-Rosenquist Foundation.

Author disclosures: GJC, GSB, and RP-E, no conflicts of interest.

Abbreviations used:

BBF

Becoming Breastfeeding Friendly

BFHI

Baby-Friendly Hospital Initiative

CAS

complex adaptive system

Code

International Code of Marketing Breast-milk Substitutes

EBF

exclusive breastfeeding

IYCF

infant and young child feeding

WBCi

World Breastfeeding Costing Initiative

WHA

World Health Assembly.