Reply to R Holla-Bhar et al.

Dear Editor:

We thank Holla-Bhar et al. for their interest and thoughtful comments on our Perspective article “What Will It Cost to Scale-up Breastfeeding Programs? A Comparison of Current Global Costing Methodologies,” which was published in September 2018 in this Journal (1). We provide our responses under the following 5 topics that we believe summarize well the comments made:

1. Comments call for recognition that the two costing methods discussed have different objectives. Our article (1) states that its aim was to provide a methodological comparison of 2 global cost analyses, and it unequivocally acknowledges that the World Breastfeeding Costing Initiative (WBCi) and the World Bank (WB) costing methodologies were developed with different objectives and both can be helpful to decision makers. We specifically stated that “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” (p. 577). We also stated that both methods can assist decision makers (p. 578) and concluded that both can potentially complement each other depending on the question(s) being asked (see Discussion section). Furthermore, we agree that WBCi can serve as a planning tool (p. 576) and also that the WB method was designed to inform the prioritization of investments by governments and other stakeholders (p. 576).

2. Comments call for acknowledging that whereas WBCi refers to implementation of the Global Strategy for Infant and Young Child Feeding, the WB method refers only to the World Health Association's Maternal, Infant and Young Child Nutrition target of enhancing rates of exclusive breastfeeding to 6 months. This topic is clearly addressed in our article (1), in which we specifically stated that “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” (p. 573). Furthermore, we stated that “[WBCi] aimed to improve optimal breastfeeding practices (i.e., early initiation, EBF [exclusive breastfeeding] for 6 mo, and continued breastfeeding up to 2 y or beyond) whereas the World Bank only targeted EBF” (p. 577).

3. In Holla-Bhar et al.’s letter, they request recognition that the WB methodology did not include crucial interventions (e.g., community support to strengthen connections between health facilities and communities). On p. 578 of our article (1), we fully acknowledged that the WB approach did not include community–health care networks costs. However, we also acknowledged that the WB package of nutrition-specific interventions included infant and young child feeding individual or group counseling and pro-breastfeeding social policies including legislation and monitoring and enforcement of policies related to the Code, the Baby Friendly Hospital Initiate, and maternity protection and leave (p. 576). Furthermore, we reported that although WBCi estimated costs for the training of community-based or volunteer support groups, the operational costs for developing, maintaining, and expanding breastfeeding support groups were not (p. 576).

4. We fully agree and acknowledge the comments made about the importance of conducting costing exercises at the country level using local costing data. As thoroughly indicated in our article (1), there is a strong need to strengthen the application of each costing method to the local national and subnational contexts (p. 578; see “Implications and recommendations for cost analyses at country level” in the Discussion section).

5. Comments imply that we are encouraging the use of the WB methodology over WBCi. The bottom line of a Perspective article is to take a position on a topic of current major importance. In this Perspective, we did so by fairly comparing the methods used to estimate the costs to create an enabling breastfeeding environment (p. 573). On the one hand, we defend our statement that currently the WB approach has a more solid methodological foundation that can be used to estimate the costs of scaling-up breastfeeding programs. For example, whereas the WB methodology stipulates a clear time frame and scaling-up pace, which is crucial information for decision makers, the WBCi does not (p. 573, 576). Furthermore, contrary to what Holla-Bhar et al. imply in their letter, the WB costing framework is based on a comprehensive core set of nutrition-specific and social policy interventions, which have proven to be effective in improving breastfeeding outcomes (p. 576). Although the WB analysis did not include all possible interventions for early initiation and continued breastfeeding, we believe that this should not be considered a methodological limitation of the WB analysis but, rather, an opportunity to expand it when warranted. On the other hand, we provided specific recommendations on how to strengthen not only the WBCi but also the WB costing methods (p. 578) and acknowledged WBCi strengths, including providing more specific guidance on estimating one-time and recurrent unit costs for breastfeeding interventions (p. 578).

We hope that our replies to these comments will help motivate further implementation research based on these two costing methodologies to determine if they can help advance the breastfeeding scaling-up agenda globally and, if so, how (2).

Notes

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