Pilot testing of the Becoming Breastfeeding Friendly toolbox in Ghana

Background: Ghana has achieved significant progress in breastfeeding practices in the past two decades. Further progress is, however, limited by insufficient government funding and declining donor support for breastfeeding programs. The current study pretested feasibility of the Becoming Breastfeeding Friendly (BBF) toolbox in Ghana, to assess the existing enabling environment and gaps for scaling-up effective actions. Methods: Between June 2016 and April 2017, a 15-person expert country committee drawn from government and non-government agencies was established to implement the BBF toolbox. The committee used the BBF index (BBFI), comprising of 54 benchmarks and eight gears of the Breastfeeding Gear Model (advocacy; political will; legislation and policy; funding and resources; training and program delivery; promotion; research and evaluation; and coordination, goals and monitoring). Available evidence (document reviews, and key informant interviews) was used to arrive at consensus-scoring of benchmarks. Benchmark scores ranged between 0 (no progress) and 3 (major progress). Scores for each gear were averaged to estimate the Gear Total Score (GTS), ranging from 0 (least) to 3.0 (strong). GTS’s were aggregated as a weighted average to estimate the BBFI which ranged from 0 (weak) to 3.0 (outstanding). Gaps in policy and program implementation and recommendations were proposed for decision-making. Results: The BBFI score was 2.0, indicating a moderate scaling-up environment for breastfeeding in Ghana. Four gears recorded strong gear strength: advocacy (2.3); political will (2.3); legislation and policy (2.3); and coordination, goals and monitoring (2.7). The remaining four gears had moderate gear strength: funding and resources (1.3); training and program delivery (1.9); promotion (2.0); and research and evaluation (1.3). Key policy and program gaps identified by the committee included sub-optimal coordination across partners, inadequate coverage and quality of services, insufficient government funding, sub-optimal enforcement of policies, and inadequate monitoring of existing initiatives. Prioritized recommendations from the process were: 1) strengthen advocacy and empower breastfeeding champions, 2) strengthen breastfeeding regulations, including maternity protection, 3) strengthen capacity for providing breastfeeding services, and 4) expand and sustain breastfeeding awareness initiatives. Conclusions: The moderate environment for scaling-up breastfeeding in Ghana can be further strengthened by addressing identified gaps in policy and programs. The Republic of Ghana is located on the Western Coast of Africa. Based on the 2010 population and housing census, the current population is estimated at about 26 million people [18]. The world bank classifies Ghana as a lower middle-income country [19]. Ghana’s health system is considered to be reasonably well developed when compared with other countries in Sub-Saharan Africa [20]. However, its performance is below that of other countries of similar income and health expenditure outside Sub-Saharan Africa. Recent evidence shows mixed performance regarding health outcomes in Ghana. While life expectancy has been gradually increasing (60 years for males; 63 years for females), there is a persistently high rate of deaths among women and children [16]. Most recent data estimates a maternal mortality rate of 164/100,000 live births and under-five child mortality of 60/1000 live births. The health system in Ghana is designed to deliver preventive health services through decentralized district and municipal service centers with the aim to increase access to services. A core component of preventive maternal and child health services is communication and support for breastfeeding. Breastfeeding services are decentralized across multiple government agencies with support from non-government partners across sectors and administrative levels. The Ministry of Health (MoH) and the GHS are the leading agencies for developing policies, legislation, and strategies for breastfeeding in Ghana [20]. Other agencies (both government and non-government) support the MoH and GHS in developing and enforcing breastfeeding policies, as well as providing technical and financial assistance for breastfeeding. Breastfeeding promotion and communication, as well as other support services, in communities and facilities, are provided, mainly, by GHS facilities as well as Teaching Hospitals which are managed by the MoH. Outside of the health sector, the Ministry of Gender, Children, and Social Protection (MGCSP) together with the Ministry of Employment and Labour Relations (MELR) works collaboratively with the MoH to promote maternity protection for breastfeeding in the workplace. The Food and Drugs Authority (FDA) also plays a regulatory role of enforcing compliance to the National Breastfeeding Regulation 2000 (LI 1667) [21] and the International Code of Marketing of Breast Milk Substitutes [13]. The activities of these government agencies are complemented by technical and financial support from multiple development partners (United Nations Agencies, Bilateral donors, and local and international Non-Governmental Organizations). The process for implementing the BBF toolbox is as outlined in the BBF implementation manual [22]. The BBF toolbox is based on the evidence-based BFGM which was developed through a rigorous consultative process involving international experts across diverse areas associated with lactation [15]. The BFGM stipulates that eight ‘gears’ must work harmoniously to achieve a country-level scale-up of breastfeeding. The BBF toolbox is designed to estimate the BBF index (BBFI) which is an aggregate score based on 54 specific benchmarks: advocacy (4 benchmarks); political will (3 benchmarks); legislation and policy (10 benchmarks); funding and resources (3 benchmarks); training and program delivery (17 benchmarks); promotion (3 benchmarks); research and evaluation (10 benchmarks); and coordination, goals and monitoring (3 benchmarks). Based on the existing situation, each benchmark is scored as 0 (no progress); 1(partial progress), 2 (minimal progress), and 3 (major progress). Benchmark scores for each gear are then averaged to estimate the Gear Total Score (GTS): 0 (gear not present), 0.1 to 1.0 (weak gear strength), 1.1 to 2.0 (moderate gear strength), and 2.1–3.0 (strong gear strength). The GTS’s are then aggregated as a weighted average to estimate the total BBF score which ranges from 0 to 1.0 (weak scaling-up environment) 1.1–2.0 (moderate scaling-up environment), 2.1–2.9 (strong scaling-up environment, to 3.0 (outstanding scaling-up environment). A key component of BBF implementation is the country committee which, in Ghana, comprised of experts from nine agencies involved in breastfeeding programming in both government and non-government agencies. The composition of the country committee is indicated in Table 1. The committee utilized available documents, expert opinion, and case studies of best practices to arrive at their decisions on the status of different aspects of the breastfeeding scale-up environment. The committee achieved this through participation in five scheduled meetings over a period of 11 months to generate GTSs for the BBFI, identify gaps in breastfeeding programming in Ghana, and develop and prioritize policy and program recommendations to address the identified gaps [15]. In between these scheduled meetings, four teams, each with a membership of three committee members, collected data (evidence from document review, and key informant interviews), and had meetings to work on scoring assigned gears and its constituent benchmarks. Recommendations were presented to key high-level stakeholders to guide strategy development and prioritization of actions to ensure a breastfeeding friendly environment. Becoming breastfeeding friendly committee membership and meeting participation aUNICEF=United Nations Children’s Fund bWorld Health Organization cUnited States Agency for International Development The BBF 5-meeting process was conducted in Ghana between June 2016 and January 2017. Preparatory activities, led by the in-country investigator, occurred earlier in March to June 2016 and involved identifying, and sensitizing key stakeholders, and inviting them to participate as country committee members. Following this, an initial list of 12 key stakeholder institutions was generated. Thereafter, each of the stakeholders/stakeholder institutions was consulted individually and provided with a brief overview of BBF and to confirm their willingness to participate. During the process, some participants who were unable to attend some of the committee meetings either sent notice to be absent or were represented by another person from their institution. As a result, by the end of the process, 15 persons from 9 institutions participated in the process (Table ​(Table11). The five-meeting process (Fig. 1) was designed to help countries reach consensus on benchmark and gear scoring over the course of 11 months, starting in June 2016 with the first country committee meeting. The aim of this 2-day meeting was four-fold. First, it was to build the capacity of the committee on the BFGM, the gears and benchmarks of the BBFI, as well as the process for scoring the benchmarks. Secondly, the meeting defined and discussed the roles and expectations of country committee members. Thirdly, during this meeting, country committee members were assigned to their respective gear teams which comprised of three members per team, with each team being allocated to work on at least 1 gear (minimum of 1 and maximum of 3 gears per team). Finally, the meeting provided opportunity for committee members to develop data gathering action workplans in which the teams identified potential data sources, data collection strategies, a timeline to review collected data and reach consensus on preliminary scores for each benchmark within their assigned gears. A gear team leader was nominated to coordinate each team’s activities, provide leadership in identifying the evidence needs of the team, communicate team progress with the Ghana BBF coordination team, document proceedings of team meetings, and present output of team work at subsequent country committee meetings. Following the workplan development, gear teams shared their workplans with the entire country committee for discussion. Input was received from other committee members as well as the Ghana BBF coordination team prior to its finalization. The Becoming Breastfeeding Friendly Process implemented in Ghana Two months later, the second meeting was convened in August 2016, for gear teams to present their data gathering progress and preliminary benchmark scores (Table 2). While most teams had made significant progress with scoring their assigned benchmarks by this time, one team (training and program delivery gear) had scored less than 20% of the gear benchmarks due to limited data available for the scoring process. Scoring progress and data gathering strategies were discussed to ensure teams had access to additional data needed to score remaining benchmarks. When consensus could not be reached on specific benchmark scores, the country committee discussed additional data source options and teams were encouraged to consult these additional data sources as they work further on completing their benchmark scoring. Becoming Breastfeeding Friendly Committee team progress in completing tasks aBBF=Becoming Breastfeeding Friendly One month later, in September 2016, the committee met for the third time for a one-day meeting where teams presented progress on benchmark scores. Prior to the team presentations, the BBF toolbox case studies were presented and provided to country committee members as a tool to assist teams in finalizing their benchmark scores. At the end of presentations, seven benchmarks still lacked accessible data needed to complete the scoring. Alternate data collection source options were discussed, and teams were tasked with: a) finalizing benchmark scores where consensus had not been reached and b) developing key gaps and recommendations for their benchmarks and gears for presentation at the 4th meeting. The country committee convened for their fourth meeting one month later in November 2016. At this one-day meeting, each benchmark was discussed thoroughly, and final consensus was reached on scores for 38 of the 54 benchmarks. For the 16 benchmarks where consensus was not reached, adequate data had not been found yet to either support scoring these benchmarks or to clearly define the gaps related to the benchmark. The committee agreed for the Ghana BBF coordination team to work directly with the respective gear teams, after the fourth meeting, to provide the evidence needed to arrive at the proposed scores. Following this process, the two gear teams secured the needed data and the scores, and data gaps details on the remaining 16 benchmarks were confirmed through email communication with the country coordination team. Since it was not possible to discuss the gaps and recommendations at the 4th meeting due to time constraints, gear teams independently developed and submitted recommendations for their respective gears to the BBF coordination team via email. A policy brief (Additional file 1: Appendix S1) and infographic (Additional file 2: Appendix S2 and Additional file 3: Appendix S3) describing the BBF GTSs and prioritized recommendations were developed in preparation for the 5th meeting. Three months later, the country committee held their fifth meeting in February 2017. This was a call to action meeting in which key stakeholder institutions involved directly or indirectly with breastfeeding programming, as well as various media institutions were invited to receive and discuss the findings and recommendations of the BBF outcomes in Ghana. Participating stakeholders represented government, United Nations, civil society, and regulatory agencies, including MELR, the MGCSP, GHS, Trades Union Congress, United States Agency for International Development, Communicate for Health, and Ghana Infant Nutrition Action Network, WHO, United Nations Children’s Fund, International Labour Organization, FDA, and the Medical and Dental Council. Following the presentation of BBF methodology and findings, which included sharing GTSs, total country score, the rationale for the scores, the gaps identified, and prioritized recommended actions, stakeholders discussed potential strategies to address the identified gaps in the national breastfeeding program. In April 2017, a meeting was organized to share the BBF process, findings, and prioritized recommendations with key high-level decision makers. The meeting was attended by the Minister for MGCSP, the Deputy Director General of the GHS, country representatives of ILO and WHO, convener of Ghana Editors Forum (a network of news media editors in Ghana), representative of Ghana Congress on Evangelisation Women’s Ministry (a women’s religious organization), and four of the 15 country committee members. Following this meeting, the Minister of MGCSP requested a concept note (which was developed by the Ghana BBF coordination team) to guide their Ministry in developing breastfeeding plans for children and women.