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Information released online before January, 2021.
A nurse at a Nigerian health care facility gets ready to cut a mother’s umbilical cord.
Courtesy of Karen Kasmauski/USAID
In November of last year, the Government of Nigeria launched three new policies aimed at promoting newborn health. One of these, the National Strategy to Scale Up Chlorhexidine (CHX), seeks to increase use of the low-cost antiseptic gel that, when applied to the umbilical cord, can significantly reduce newborn deaths. According to the World Health Organization, newborn babies make up roughly a third of all deaths of children under age 5 in Nigeria.
And while other causes of newborn deaths are more common here than infections—including premature births, lack of oxygen to the brain (also known as birth asphyxia) and pneumonia—infection via the umbilical cord is frequent and deadly, yet also preventable. When applied to a newborn’s umbilical cord in high-risk settings, CHX has been shown to reduce severe infection by 68 percent and mortality by 23 percent, potentially saving over 300,000 lives globally each year.
Recognizing the need for a practical strategy and implementation plan to scale up this life-saving commodity in Nigeria, USAID, through its flagship Maternal and Child Survival Program, brought together partners like the Clinton Health Access Initiative to support the Ministry of Health.
“Chlorhexidine is an evidence-based, cost-effective intervention that can significantly impact neonatal mortality in Nigeria. Since 2012, we at USAID have been working with other partners under the leadership of the federal Ministry of Health to successfully introduce chlorhexidine into Nigeria,” says Dr. Joseph Monehin, team lead for integrated health/reproductive, maternal, newborn and child health at USAID/Nigeria. “USAID is happy to have played a role in the development of an action plan to implement scale-up of chlorhexidine.”
The Nigerian Government’s current goal is to ensure that at least half of all newborns in the country receive CHX after the fifth year of implementation of the strategy, which is government-led and uses multiple outreach channels to strengthen markets. If the strategy is successful, officials say it could reach 10.9 million newborns and save up to 55,000 lives in Nigeria.
“The National Chlorhexidine Scale Up Strategy document highlights the government’s drive to ensure that CHX is readily available and used across the country for umbilical cord care. This is one of the 13 life-saving commodities stipulated by the U.N. Commission on Life-Saving Commodities for Women and Children and adopted for accelerated access and use in Nigeria,” said Minister of Health Isaac Adewole during a November 2016 World Prematurity and Pneumonia Day press briefing held in Abuja and reported in the local Guardian newspaper.
The strategy focuses on five core components: market and user; manufacturing and distribution; clinical and regulatory elements; policy, advocacy and financing; and last but not least, coordination for leadership and accountability.
“This strategy not only outlines the resources needed to achieve specific targets over a five-year period at the national level, but also includes guidance for developing operational plans at the state level and assigns roles and responsibilities to all the stakeholders involved,” says Dr. Olayinka Umar-Farouk, senior newborn health specialist with USAID’s Maternal and Child Survival Program.
CHX was first introduced in Nigeria through USAID’s Targeted States High Impact Project (TSHIP) on maternal and newborn health in Sokoto and Bauchi states back in 2012. These two northern states were targeted because of their high child and maternal mortality rates. Over the course of the project, the use of CHX increased by 25 percent in Bauchi state and by 17 percent in Sokoto state.
Many factors have contributed to the successful scale up of CHX in these two states, including a total market approach that involved local leaders, the continuous training of health care providers, the participation of the private sector and an aggressive marketing campaign. Local government immediately purchased CHX, which is affordable and easy to use, through regular procurement channels.
“I have used chlorhexidine on two of my grandchildren,” says Alhaja M. T. Badmus, a grandmother of 12. “I found it easy to apply compared with methylated spirit [alcohol]. Their umbilical cords healed within seven days.”
The national strategy will build from early local successes. Umar-Farouk says that some of these lessons include “the need for ongoing implementation and coordination of stakeholders and partners to ensure early engagement and buy-in; the need to integrate scale up of CHX to other maternal and newborn health priorities; the importance of tracking key CHX indicators in the national health management information system; and the need to engage the private sector in ensuring supply of and generating demand for CHX.”
Alh Faruk Malami Yabo, commissioner for local government in Sokoto state, adds, “The other thing that makes it work is the involvement of the community. We have done this through the creation of the ward development committees.”
Nigeria is one of many countries with high levels of newborn mortality rates where USAID is supporting the adoption of this simple life-saving product. Over the past five years, USAID has led the introduction and scale of CHX through a variety of activities, including funding clinical trials in Asia and Africa, advocating for the inclusion of CHX in the U.N.’s list of life-saving commodities for women and children, formalizing a CHX working group to drive and coordinate global scale, and awarding a Saving Lives at Birth Grand Challenge for Development on CHX that contributed to reducing neonatal mortality in Nepal by 34 percent.
“In 2014, USAID developed a global scale-up strategy for CHX, which looked to build from successes in Nepal and focus on critical supply and demand levers to guide global and country-level activities to introduce and scale CHX,” says Nikki Tyler, market access adviser with the Center for Accelerating Innovation and Impact at USAID’s Bureau for Global Health. “This analysis prioritized Nigeria for national CHX scale-up, and our team was proud to work with the Ministry of Health, USAID/Nigeria and our implementing partners to develop an operational launch plan that outlined activities, roles and responsibilities, and resources needed to scale-up chlorhexidine at the national level.”
“Nigeria’s national strategy to scale up the use of CHX, which outlines a clear role for the private sector, is a great model for other countries and commodities looking to strengthen markets and improve health outcomes,” says David Milestone, acting director of the Center for Accelerating Innovation and Impact. As such, the strategy serves as a model for other countries looking to scale chlorhexidine or other life-saving commodities.
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