Chlorhexidine Use Experience: Program and Policy Implications in Sub-Saharan Africa
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1) Chlorhexidine use for umbilical cord care has been shown to reduce neonatal mortality in multiple countries in Sub-Saharan Africa. Nigeria has scaled up chlorhexidine use, distributing it alongside misoprostol for postpartum hemorrhage prevention. 2) In Sokoto State, Nigeria, over 87,000 newborns have received chlorhexidine gel and over 87,000 mothers have received misoprostol through a community-based distribution model involving 3,800 volunteers and health workers. This has increased access to maternal and newborn care. 3) Lessons from Sokoto's experience indicate that community engagement, advocacy, effective forecasting and distribution are key to successfully
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Chlorhexidine Use Experience: Program and Policy Implications in Sub-Saharan Africa
- 1. Chlorhexidine Use Experience: Program and Policy Implications in Sub-Saharan Africa Olayinka Umar-Farouk, MD, MBA Nosa Orobaton, MD, DrPH, MBA Uganda’s Maternal and Newborn Health Conference June 16, 2015
- 2. 2 Objective • Share programmatic experience and lessons learned on use of 7.1% Chlorhexidine digluconate (CHX) for umbilical cord care in Sub-Saharan Africa with an emphasis on Sokoto State in Nigeria. See page 67 to 81 at www.slidedocs.com
- 3. 3 Why use Chlorhexidine for cord care? • Prevents sepsis • Common portal of entry • Harmful current cord practices • CHX application history • Evidence-based intervention • User-friendly • WHO recommended
- 4. 4 Evidence-based Approach Sarlahi District, Nepal: 2002-20061 • 34% lower mortality among neonates if initiated within 24 hours (single application of CHX) Sylhet District, Bangladesh: 2007-20092 • 20% lower mortality among neonates (single application of CHX) Sindh Province, Pakistan: 2008-20093 • 38% lower mortality among neonates (daily application for one week) 1. Mullany et al, Lancet 2006 2. Arifeen et al, Lancet 2012 3. Soofi et al, Lancet 2012
- 5. 5 WHO Recommendation on Cord Care “Daily chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or gel, delivering 4% chlorhexidine) application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality (30 or more neonatal deaths per 1,000 live births). Clean, dry cord care is recommended for newborns born in health facilities and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance, such as cow dung, to the cord stump.” WHO 2014
- 6. Glance at African countries that have introduced CHX into the health system and their current status of implementation Overview of Country and CHX Indicators
- 7. 7Global CHX Working Group 2015 Chlorhexidine Across Sub-Saharan Africa
- 8. 8 Ethiopia 1. CIA World Factbook 2014 estimation 2. UNICEF 2012 Population: 96,633,4581 Neonatal Mortality Rate: 29 neonatal deaths per 1,000 live births2 9.9%, 89.7% Facility Births Home Births Current Status: Introduction Year of Introduction: 2014 Regimen: Multiple-day Dosage Formulation: Gel Chlorhexidine Data:
- 9. 9 Liberia 1. CIA World Factbook 2014 estimation 2. DHS 2013 Population: 4,092,3101 Neonatal Mortality Rate: 26 neonatal deaths per 1,000 live births2 Current Status: Introduction Year of Introduction: 2014 Regimen: Multiple-day Dosage Formulation: Gel Chlorhexidine Data: 36.9% 61% Facility Births Home Births
- 10. 10 Democratic Republic of Congo 1. CIA World Factbook 2014 estimation 2. DHS 2013-2014 Population: 77,433,7441 Neonatal Mortality Rate: 28 neonatal deaths per 1,000 live births2 Current Status: Scale Up Year of Introduction: 2014 Regimen: Multiple-day Dosage Formulation: Liquid & Gel Chlorhexidine Data: 74.9% 22.6% Facility Births Home Births
- 11. 11 Madagascar 1. CIA World Factbook 2014 estimation 2. UNICEF 2012 Population: 23,201,9261 Neonatal Mortality Rate: 22 neonatal deaths per 1,000 live births2 Current Status: Scale Up Year of Introduction: 2013 Regimen: Single-day Dosage Formulation: Gel Chlorhexidine Data: 35.5% 64% Facility Births Home Births
- 12. 12 Malawi 1. CIA World Factbook 2014 estimation 2. UNICEF 2012 Population: 17,377,4681 Neonatal Mortality Rate: 24.2 neonatal deaths per 1,000 live births2 Current Status: Scale Up Year of Introduction: 2014 Regimen: Single-day Dosage Formulation: Gel Chlorhexidine Data: 73.4% 24.3% Facility Births Home Births
- 13. 13 Nigeria 1. CIA World Factbook 2014 estimation 2. DHS 2013 Population: 177,155,7541 Neonatal Mortality Rate: 37 neonatal deaths per 1,000 live births2 Current Status: Scale Up Year of Introduction: 2013 Regimen: Multiple-day Dosage Formulation: Gel Chlorhexidine Data: 35% 63.1% Facility Births Home Births
- 14. Program experiences and results from Sokoto State in Nigeria Nigeria Lessons Learned and Results
- 15. 15 Sokoto State Woman in labor at home in Sokoto, Nigeria
- 16. 16 Program Approach in Sokoto, Nigeria Input Process Outcome CHLORHEXIDINE & MISOPROSTOL SUPPLY BY STATE GOVERNMENT HEALTH FACILITIES COMMUNITY HEALTH VOLUNTEERS COMMUNITY HEALTH RESOURCES & COMMUNITY OWNERSHIP WARD DEVELOPMENT COMMITTEES COMMUNITY DRUG KEEPERS MOTHER NEWBORN DYAD INCREASE MATERNAL SURVIVAL INCREASE NEWBORN SURVIVAL DECREASE MATERNAL & NEONATAL MORBIDITY Procurement Trainings Distribution Impact Measurement Distribution Supervision OutcomeTracking Policy Decision Review Meetings Analysis
- 17. 17 Results Chlorhexidine distribution is twinned with Misoprostol for preventing postpartum hemorrhage About 100-150 women and newborns access the commodities daily 87,423 newborns have received CHX gel and 87,389 mothers have received misoprostol 3,800 volunteers and health workers have been trained on CHX application and administering misoprostol
- 18. 18 Results • Community ownership, engagement, and empowerment • 31 out of 37 states have visited Sokoto state for a learning visit
- 19. 19 Results • Public private partnership • Stimulus for local production • Accelerated government commitment • Review of policy documents, training manuals, drug list
- 20. 20 Policy Guidelines • Clear national leadership and commitment • Integration of health program • Community based approach • Involvement of all stakeholders from the beginning • Public private partnership • Leverage resources from other country programs • Ensure funding commitments • Define supply strategy • Identify metrics
- 21. 21 Lessons: Demand Side • Broad-based advocacy is key: religious, traditional, professionals, multi-media • Community-based distribution key to reach last mile • Bridge information arbitrage • Proactive, comprehensive forecasting to prevent shortages • Promote use of best practices
- 22. 22 Lessons: Demand Side • Proactive, responsive National Drug Regulatory Agency • Integrated community-to- manufacturer-buyer learning platform • Effective distribution channel • Multiple approach to creating awareness • Integrate into delivery kits
- 23. 23 JSI’s model for CHX scale up
- 24. Approaches that consider local context and engage local stakeholders are likely to be successful. In every context, regardless of the number of challenges being faced, there is always a way to promote quality MNH care, but the solution should be generated by and with local stakeholders. Response #15 from SCUS-MHTF Survey 2014
- 25. Olayinka Omar-Farouk Nosa Orobaton For more information, please contact us at: oumarfarouk@tshipnigeria.org norobaton@tshipnigeria.org Thank you!