The 2018 implementation guidance for the Baby-Friendly Hospital Initiative (BFHI) recommends institutionalising the ten Steps through nine national responsibilities for universal coverage and sustainability. As countries adapt BFHI programmes to this paradigm shift away from traditional designation programmes, documenting and sharing policy and programme experience are critical and currently sparse. This qualitative case study included desk reviews of published and grey literature on BFHI programming, national plans and policy documents specific to the selected national responsibilities for universal coverage and key informant (KI) interviews across a range of actors. In the Kyrgyz Republic, the case study explored responsibility 5, development and implementation of incentives and/or sanctions, and responsibility 6 in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring [7] communication and advocacy [8] and financing [9]) as they relate to the universal coverage of the targeted responsibilities were also explored. Thirty-eight respondents in the Kyrgyz Republic described approaches that were used in the health system, including BFHI designation plaques, performance-based financing and financial sanctions. However, currently, there are no formal incentives and sanctions. In Malawi, TA was utilised for national planning and to introduce quality improvement processes. Forty-seven respondents mostly described provisions of TA in building and strengthening the capacity of providers. More programmatic evidence to demonstrate which types of incentives or sanctions can be effective and sustained and more documentation of how TA is provided across multiple aspects of implementation are needed as countries institutionalise BFHI.

The World Health Organization (WHO) and United Nations Children's Fund (UNICEF) recommend exclusive breastfeeding (EBF) for the first 6 months of life. To estimate the proportion of infants that are exclusively breastfed, many agencies use the point prevalence of EBF among infants currently 0-5.9 months of age, as recommended by WHO and UNICEF. This measure tends to overestimate the percentage of infants that are exclusively breastfed for the entire recommended period. We compared five methods of measuring EBF, using data from three large-scale cross-sectional surveys. The five methods were: the WHO/UNICEF recommended method (EBF-24H); an estimate of EBF for 6 months, using the 24-h recall among infants 4-5.9 and 6-7.9 months (EBF-24H-Pul); a since birth recall (EBF-SB); an estimate of EBF for 6 months, using the since-birth recall among infants 4-5.9 and 6-7.9 months (EBF-SB-Pul); a retrospective measure of EBF collected from infants 6-11.9 months, based on the age of introduction of liquids and foods (EBF-AI). EBF-24H-Pul and EBF-SB-Pul produced lower estimates of EBF than other measures, while also aligning better with the WHO recommendation, but may be difficult to estimate from multipurpose surveys due to sample size limitations. The EBF-AI method produced estimates between these, aligns well with the WHO recommendation and can be easily collected in large-scale household surveys.

Background Globally, growth monitoring and promotion (GMP) of infants and young children is a fundamental component of routine preventive child health care; however, programs have experienced varying degrees of quality and success with enduring challenges. The objective of this study was to describe implementation of GMP (growth monitoring, growth promotion, data use, and implementation challenges) in two countries, Ghana and Nepal, to identify key actions to strengthen GMP programs. Methods We conducted semi-structured key informant interviews with national and sub-national government officials (n = 24), health workers and volunteers (n = 40), and caregivers (n = 34). We conducted direct structured observations at health facilities (n = 10) and outreach clinics (n = 10) to complement information from interviews. We coded and analyzed interview notes for themes related to GMP implementation. Results Health workers in Ghana (e.g., community health nurses) and Nepal (e.g., auxiliary nurse midwives) had the knowledge and skills to assess and analyze growth based on weight measurement. However, health workers in Ghana centered growth promotion on the growth trend (weight-for-age over time), whereas health workers in Nepal based growth promotion on measurement from one point in time to determine whether a child was underweight. Overlapping challenges included health worker time and workload. Both countries tracked growth-monitoring data systematically; however, there was variation in growth monitoring data use. Conclusion This study shows that GMP programs may not always focus on the growth trend for early detection of growth faltering and preventive actions. Several factors contribute to this deviation from the intended goal of GMP. To overcome them, countries need to invest in both service delivery (e.g., decision-making algorithm) and demand generation efforts (e.g., integrate with responsive care and early learning).