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 | |
BFHI, 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.
Target rates for optimal breastfeeding practices (i.e., early initiation, EBF, continued breastfeeding) after programs were implemented were not specified by WBCi.
“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.
Maternity leave is associated with an increase in EBF, but the effect is not specific to maternity leave cash benefits (12).
Unclear based on methods and results if existing levels of program coverage were factored into the WBCi analysis.
WBCi stated “full implementation” of programs and policies in Global Strategy for IYCF, we assumed this was 100% program coverage.
WBCi 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.
The 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.
Multiplier 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.
Financial need formula was not presented by WBCi, we adapted the presented formula based on the study's written methods.
Interventions can have ≥1 unit costs.
For 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.
“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.
Costs were converted to US dollars ($) and unit costs were inflated to 2012 values in WBCi and 2015 values in World Bank.
The 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.
Cohorts 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.
Cost per child formula was not presented by WBCi or the World Bank; we adapted the presented formula based on the studies’ written methods.
Cost per child for each intervention is presented in this study; we present only the total, one-time, and recurring costs.