The 2018 implementation guidance for the Baby-Friendly Hospital Initiative (BFHI) recommends institutionalizing the Ten Steps through nine national responsibilities for universal coverage and sustainability. In the Kyrgyz Republic, the case study explored responsibility, development and implementation of incentives and/or sanctions, and responsibility in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring communication and advocacy and financing) as they relate to the universal coverage of the targeted responsibilities were also explored.