Updates on the rollout of Chlorhexidine for Cord Care (CHX) & Misoprostol use in Sokoto State, NIGERIA

Dr. Nosa Orobaton Dr. Kamil Shoretire Dr. Goli Lamiri Dr. Abubakar Maishanu Dr. Ibrahim Kabo et al
13 April 2013

TSHIP Targeted States High Impact Project

On USAID/JSI-TSHIP

USAID-funded (Oct. 2009-Sept. 2014) Cover service delivery in MNCH, FP & RH Based in Sokoto and Bauchi States Cover Health Systems strengthening Governance-focused Aligned with Nigerias Saving One Million Lives Initiative

A Profile of Sokoto State, Nigeria

4.4 million people 23 Local Government Areas 244 political wards Seat of Caliphate, Supreme leader of Islam, Nigeria Illiteracy Rate is 83% Total Fertility Rate is 8.7 95% of all Deliveries occur at home 25% of all Deliveries occur with Zero persons present

Key Milestones

Sokoto Govt. purchased 1st batch of 56,000 doses each of CHX, Miso PPP delivers first in Africa CHX State-wide, Community-Based Distribution system set up 918 of 1220 Community Drug keepers trained and certified Dossier on CHX prepared with Nigeria NAFDAC

CHX 4% registered with NAFDAC and procured by Sokoto State government

Key Milestones Contd

Govt of Nigeria uses Sokoto experience to issue Call-to-Action to all 36 governors Bauchi state govt engaged, issued memo to procure CHX, Miso Outreach to at least 3 state governments commenced

Sokoto launch- Governor of Sokoto State & Minister of Health, March 8, 2013

They Said Yes to CHX & Miso Based on Evidence

Governor Aliyu M. Wammako of Sokoto State is the first governor in Nigeria to finance state-wide use of Miso and CHX. Has asked for the report 30 days after distribution of CHX and Miso to Communities.

Alhaji Farouk Malami Yabo, Sokoto Commissioner of Local Government, sold the idea of CHX and Miso for state-wide use to Governor Wammako

Call to Action by Hon. Minister of State for Health, Dr. Muhammed Ali Pate (heard by 100 Million Nigerians)

I applaud the Sokoto State Government for their leadership in pioneering the procurement of two life-saving commodities: Chlorhexidine Gluconate 7.1% (CHX) and Misoprostol for the survival of newborns and mothers, respectively. I invite other State Governments to emulate this commendable initiative of the Sokoto State Government in their respective states and contribute to our national efforts of Saving One Million Lives by 2015.....
Signed in Abuja, March 13, 2013

Available at: http://www.tshipnigeria.org/images/Call%20to%20Action%20by%20Honourable%20Minister%20of%2 0Health%20of%20State%20of%20S.pdf

What we tested in Sokoto in Oct. 12: Pre-order, Pre-policy approval, with Supplier
The users: Women Tired and by self Women aged 21-38 yrs Literacy levels varied Most had experienced parturition Home delivery Yes, no one present Liquid vs. gel? Liquid-spray vs. topical Who applies it? Me vs. TBA?

Creating a Market of Users: Formative Research Findings

Mothers want what works: Listen! want control want to be sure medicine once applied, stays put want assurance of good mother---multi-use? Identify package with image of child What formulation then? GEL.

Creating a System for Distribution to Users in Sokoto: Community Based, Community Managed

Distributing what? Knowledge Application capabilities Chlorhexidine gel/Misoprostol Cultivating local trust linking back to health facility Supply chain right to community The Political Ward-Unit of Consideration MOLG>Health Facility (1)> Drug keepers (5)>CBHV(10)

Training of Midwives on Proper Use of CHX

Counseling Card for CHX application

Counseling Card for CHX Application

Roll-Out of CHX at Scale in Sokoto

244 Ward Development Committees (WDC) in Sokoto, briefed by state govt 918 of 1220 drug keepers trained CHX and Miso packaged for one HC per political ward CHX & Miso to HC for distribution to Drug keepers planned for April 2013

Creating a Market of Local CHX Suppliers

Vibrant market in Nigeria Highly consolidated Strong industrial capacity Chlorhexidine familiar Keen small companies Wait and see mentalityShow me the market!

Measuring Program Efforts

Build into routine M&E Systems LQAS NDHS 2013 and beyond

Measuring Program Efforts: Indicators for CHX and Misoprostol Program

Number of LGAs where CHX & Miso is introduced

Number of Health Workers trained on CHX and Miso

Availability of CHX and Miso with Communities

Availability of CHX and Miso at health Facilities

Measuring Program Efforts: Indicators for CHX and Misoprostol Program

Percentage of mothers/care takers who received CHX tube/Misoprostol tablets

Percentage of mothers who reported applying no substance other than CHX in the freshly cut cord stump

Percentage of deliveries by Skilled Birth Attendant

Neonatal Mortality Rate

Some Considerations

Local trust: Balancing speed & prudence Nesting CHX-Miso into health eco-system Including more women into PHC-CHX decision architecture Balkanized health facilities Local Production of CHX Going to National scale intensifiedCall for speed

Members of 100 Women Group, Yabo, Sokoto

Some additional Considerations

Mother-newborn as a dyad: MisoprostolCHX Keep husbands and male leaders engaged The key resources to be activatedgovernance and resolve Working to secure the next order of CHX and Miso

Concluding Remarks

Cultivating local trust and local ownership: balance with speed More buyers..... more momentum Local production is an imperative-GMP, incentives Documentation of lessons ongoing

One of the early recipients of CHX: Abdulrahman I. Alhassan born 2/1/ 2013

Governance, Leadership and Stewardship: As It Should Be

For more information go to: http://www.jsi.com/JSIInternet/index.cfm

References

National Demography & Health Survey (NDHS) 2008. Nigeria Bureau of Statistics, 2012.