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Dr. Katharina Lichtner
Managing Director, Family Larsson-Rosenquist Foundation
The operationalization of a country’s breastfeeding policy is one of the Foundation’s key projects. What does this mean?
This is the transformation of a country’s breastfeeding goals from political aspirations into a nationwide, comprehensive, multi-year actionable plan to sustainably improve the breastfeeding environment. The operationalization method integrates ongoing activities, describes different demographic target groups of women, uses a human-centered design approach to identify key issues they face, identifies appropriate interventions, and includes expected overall costs based on a concise implementation road map. It is systematic, incorporates current relevant evidence, and is tailored to a country’s existing systems, like the health and education systems.
How did this become a central focus of the Foundation?
You could say we grew into it. While developing the Foundation’s strategy, we noticed the close connection between academia and politics working towards well-articulated health policies. At the same time there are breastfeeding-promoting projects from different organizations happening in parallel in communities, often without any coordination. However, discussions around translating a breastfeeding policy into an actionable plan were missing. We find there is a robust understanding about why breastfeeding should be promoted and what needs to be done. However, how to effect the needed change is less well understood. This “know-do” gap poses a great obstacle to sustainably improve a country’s breastfeeding environment. We saw this as an opportunity to develop innovative ideas to help close this “operationalization gap” and globally improve mother and child health.
What is innovative about this method?
There are three highlights. At the highest level, we are advocating a paradigm shift away from individual solutions towards a process-based approach. Why women may find it hard to breastfeed always reflects a complex mix of issues that can’t be solved by any individual intervention. Second, we wanted to find a practical way to integrate the necessary scale-up from the beginning. This led to the creation of an innovative target group stratification or “persona” concept. And finally, we wanted to facilitate easy integration of scientific findings into operational planning, which led to the development of a taxonomy to connect the dots between barriers to breastfeeding and tried interventions.
You are testing the method in Ghana. How do you go about it?
We approach this as a co-creation project with the Ministry of Health and Ubora Institute. Together, we’re turning a theoretical method into a process that works in practice. We are very pleased to say the method is working, and we are now completing a five-year fully costed plan, outlining how Ghana can sustainably improve its breastfeeding environment. It has been demanding but extremely rewarding collegiate work over the last two and a half years. We expect to finalize the plan in mid-2024 and by the end of the year, we expect to make the method, templates and tools freely available.
The operationalization gap
Scientific findings are necessary but not sufficient to positively impact public health. To drive this change, original findings must be aggregated, translated into practice, and disseminated, with a plethora of stakeholders coming together to make it happen. This is conceptualized in the knowledge value chain graphic shown here which we developed as a core element of our strategy, illustrating the transformation process that guides much of our work.
Whilst the translation of scientific findings into policy is well established, it is a different story post policy. Activities are highly fragmented, often uncoordinated, wrongly sequenced and executed by multiple parties, sometimes with conflicting agendas. The result? Efforts to increase breastfeeding rates are not as effective, capital-efficient or sustainable as they could be.
The operationalization method
However, by moving to a comprehensive, multi-year plan, positive, lasting impact is more likely. To achieve this, the operationalization method includes five distinct steps:
1. A transparency phase outlining past and existing improvement efforts, and identifying key influencers and stakeholders, country-specific scientific literature and current breastfeeding policy elements.
2. Developing “personas” – i.e., demographically stratifying all women of childbearing age into target groups, or personas – for the subsequent analysis phase – and as a basis for implementation at scale.
3. An analysis phase using semi-structured interviews to identify major breastfeeding barriers and prioritize them. In Ghana, approximately 400 interviews with mothers and key influencers were completed.
4. A strategy development and planning phase, where appropriate solutions, organizational requirements and an implementation roadmap are defined.
5. A costing phase, where a comprehensive, adaptable financial plan is developed, including a funding strategy if countries are not able to assume the costs with existing budgets.
The operationalization advantages
A comprehensive, multi-year plan offers distinct advantages. It enables governments to “own” and better coordinate post-policy implementation processes. Activities can be aligned with health, education or other systems, drawing on existing resources. They can be properly sequenced, and synergies can be realized. Furthermore, capacity building and retention will improve because expertise is built within the country. Overall, funding-to-impact ratios and sustainability should improve considerably.
The method also improves countrywide implementation at scale. At the heart is an innovative approach of defining personas, groups of women with similar socioeconomic realities, based on demographic data. This serves three main purposes: to identify major barriers to successful breastfeeding for each persona, to provide information about how to best reach them for intervention delivery, and lastly, to provide information about numbers and locations – all critical to developing robust scale-up approaches and determining the associated implementation costs. We believe using personas from the beginning safeguards against focusing on solutions that work in small pilots but fail to scale up due to cost or technical impediments.
In the early phases of developing the operationalization method, it became clear that governments would need support either due to a lack of sufficient staff and/or a lack of relevant skill sets. Hence, the Foundation is concomitantly funding and building a social enterprise in Ghana to serve as an operationalization competence center. It has found the perfect home at its partner Ubora Institute, a social enterprise itself. The new competence center unit will support Ghana and other countries in West Africa. We plan to use this business model as a blueprint for setting up other social enterprises in the Global South.
The “Breastmilk for Life” project
Since the start of 2022, we have been co-creating and testing the operationalization method in Ghana with the Ministry of Health and Ubora Institute. We have successfully completed the first four steps and expect to successfully complete the fifth step soon. We were excited to confirm that each step, thanks to its systematic but flexible design, worked as planned with minor modifications. We identified the best practical approach for each step, including an AI application that was expressly programmed to greatly shorten the interview analysis needed to identify breastfeeding barriers. We are currently preparing the method and learnings for publication and will compile everything into a freely available, comprehensive handbook to enable other countries to implement Breastmilk for Life.
We hope that the operationalization method will be a catalyst to improve breastfeeding rates around the world. Ultimately, we hope it will also be adopted for wider public health and nutrition initiatives, to improve infant and mother health globally and thus contribute to reaching the UN Sustainable Development Goals.