Better cord care saves babies lives: Chlorhexidine Navi (cord) Care Program in Nepal

Dr. Purusotam Raj Shedain, Ministry of Health and Population, Nepal Leela Khanal, Project Manager, CNCP, Nepal 1

The Nepal Context- Child Mortality

Under five mortality rate Infant mortality rate Neonatal mortality rate 118 91 79 64 50 39 61 54 48 33 46 33 54 34 16* 2001 2006 2011 2015
Source: NDHS&NHSP*

180

160

153

140

120

100

102

Marked decline in infant and child mortality

80

60

46

40

20 1996

Less improvement with neonatal mortality and no change from 2006-2011

1991

Causes of Neonatal Deaths Nepal

Per hour 3 -4 neonates die in Nepal
Severe infections 42%

Other 10%

Congenital Anomaly 8%

Pre term/LBW 6%

Birth Asphyxia 15%

Injury 19%

Neonatal mortality61% of the under five mortality and 75% of infant mortality

Source :NDHS, 2006

The Nepal Context- Delivery

63% deliveries at home

82 % used clean delivery kit or new/boiled blade

41% of babies had some material on stump.

Source : NDHS, 2011

Nepal Context Policy

Strategies to reduce neonatal mortality

Expansion of community-based neonatal care program and role of community level health workers

Promote institutional delivery and Skilled Birth Attendant

Why 7.1 % w/v Chlorhexidine Navi (Cord) Care ?

An estimated 1 in 6 neonatal deaths could be averted with Chlorhexidine cord care.

A simple technology with potential to prevent 500,000 global neonatal deaths annually.
Soure : Hodgins et.al(2013)

Application of 7.1% w/v chlorhexidine digluconate in freshly cut umbilical cord stump can reduce neonatal mortality by 23%

68% reduction in serious infection

Source: Mullany (2011).

Why Nepal Accepted Chlorhexidine Cord Care

Addressing a problem with high population health burden

Efficacy

Low cost

Simplicity

Safety

Acceptability

Low regulatory requirements

Health system compatibility

Scalability
7

Commercial viability

Nepal: A Living University for Chlorhexidine Cord Care

2007

1st consultative meeting in Nepal

Non-inferiority trial of CHX gel compared to aqueous 2008-09 Gel versus aqueous community acceptability study

Pilot program in four districts

2009-11

Nepal: A living university for Chlorhexidine cord care

Coverage and compliance study

CHX international meeting at Banke, Nepalgunj Approval from MoHP for national level scale up 2009-11 Saving Lives at Birth: a Grand Challenge for Development Better Cord Care Saves Babies Lives, Three year project by JSI to support scale up CHX as a national program.

Nepal: A Living University for Chlorhexidine Cord Care

Providing technical and product support to neighboring Asian and several African countries for doing formative work and preparing to pilot 2012 Providing a learning platform to Onwards many international visitors Providing technical support to other implementing partners

Chlorhexidine Implementation Status

N
Humla

Far-Western Region

Darchula

Mid-Western Region
Mugu

Bajhang

Baitadi

Dadeldhura Jumla Kalikot Mustang

Doti

Achham

Western Region
Manang

Kanchanpur Jajarkot Rukum Surkhet Myagdi Salyan Baglung Rolpa Lamjung Rasuwa Banke Pyuthan Gulmi Syangha Arghakhanchi Palpa Dhading Kapilvastu Rupandehi Chitwan Makwanpur L Ramechhap Sindhuli Parsa Nawalparasi Nuwakot K B Kavre Tanahu Sindhupalchowk Dolakha Dang Kaski Gorkha

Dailekh

Kailali

Central Region

Eastern Region
Solukhumbu Sankhuwasava Taplejung

Pilot-4 districts

Okhaldhunga Khotang Bhojpur Bara Udayapur Sarlahi Mahottari Dhankuta Dhanusha Siraha Ilam Rautahat*

Completed- 28 districts including pilot Ongoing- 9 districts

Planned for 2013- 13 districts

Saptari

Morang

Jhapa

Scale up at national level by 2015

Implementing partners NFHPII Plan Nepal UNICEF Save the Children Health Right International Care Nepal
11

Chlorhexidine Navi Care Program

One Heart Worldwide

Strategic Approach
Community based neonatal care program

Social marketing Integrate Chlorhexidine as a part of ongoing government program

Use Chlorhexidine in health facility delivery

Chlorhexidine with Misoprostol

Skill birth attendant training curriculum

12

Implementation approach

Chlorhexidine orientation to stakeholders and staff of DPHO/DHO Orientation to FCHVs Availability of service at home birth

Orientation to service providers of all level FCHVs distributes CHX to pregnant mother at 8th month of pregnancy after counseling

Service delivery at hospital and peripheral health facility

Monitoring and quality assurance

13

Key to Program Success in Nepal

Benefit of conducting the first RCT in Nepal

Government leadership since inception of the program

Local manufacturer (Lomus Pharmaceutical) producing a good-quality product

Grand Challenge for Development award to JSI R&T to support GoN to scale up chlorhexidine Navi Care program as a national program

Partners and professional organisation involvement in scaling up

Nepal member of global Chlorhexidine working group member 14

Supply of 7.1%w/v Chlorhexidine in Nepal

3 gram of 7.1% Chlorhexidine digluconate gel tube - Nepali brand name Kawach.

Pictorial instruction inside box.

Current price is Rs.18 ($0.23) for Government.

Supply is ensured through the government logistics supply system. Job aid to counsel mother

Doll as a Interpersonal Communication Tool

Every FCHV and HF received baby doll as a IPC tool to teach mother and family about Chlorhexidine application procedure and other essential newborn care

This is being a center for attraction in some district know as Putali (doll) Program

Ensuring Sustainability

Chlorhexidine added in Essential Drug List of Nepal

Chlorhexidine cord care is a part of an essential newborn care

Government of Nepal included Chlorhexidine procurement in multi-year procurement plan

Included in routine health information system for recording and reporting

Lessons Learned

Rapid scale up is possible through the existing government health system

Traditional harmful practices of cord care can be replaced

Multiple possible distribution channels for high coverage and potential for direct consumer use

Highly acceptable and functional through community mobilization

Challenges

WHO position (1998) understood to be against antiseptic use

Program shifting for cord care may create confusion in service provider and even in policy makers for transition period

Product availability

Ensuring quality of roll-out vs. government ownership

Continuing impact at scale- Supply chain, HMIS (Coverage tracking, ongoing performance management (e.g. review meetings)

References:

Hodgins S, Pradhan YV, Khanal L, Upretti S, KC NP. Chlorhexidine for umbilical cord care: game-changer for newborn survival? Glob Health Sci Pract. 2013;1(1):5-10. http://dx.doi.org/10.9745/GHSP-D-12-00014

Mullany , L(2011) Chlorhexidine Cord Cleansing. Summary and Meta Analysis of South Asian Trials

Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland.

20

Thank You

21