Innovation in reducing neonatal death using Chlorhexidine in Nepal- a case study

• This is three year project to scale up use of
Chlorhexidine at national level
• The project aim to reduce neo-natal death cased by infection by using Chlorhexidine immediate after cord cutting
• This in one of the innovation project under
USAID health , science and technology.
2

The Nepal Context- Child Mortality
180
160
140
120
100
80
60
40
20
0
3
153
102
118
Under five mortality rate
Infant mortality rate
Neonatal mortality rate
91
Marked decline in infant and child mortality
79
46
50
64
39
61
48
33
1991
Less improvement with neonatal mortality and no change from 2006-2011
1996 2001 2006
54
33
46
54
34
16*
2011 2015
Source: NDHS&NHSP*

Other
Congenital
Anomaly
Pre term/
LBW
Birth Asphyxia
Injury
Severe infections
42%
3 – 4 children die every hour

63% of deliveries occur at home

Child birth considered an impure and dirty process

7
Nepal Context – Policy
Strategies to reduce neonatal mortality
Expansion of community-based neonatal care program
Promote institutional delivery and Skilled
Birth Attendant

• Chlorhexidine will be applied to each newborn irrespective of facility and home birth.
• Nepal is using single dose resume immediate after cord cutting as a part of essential newborn care followed by clean and dry cord care practices.
• CHX is not stand alone program it is integral part of essential newborn care.
8

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
Commercial viability
9

Nepal: A Living University for Chlorhexidine Cord
Care
•
1 st consultative meeting in Nepal
2007
2008-09
• Non-inferiority trial of CHX gel compared to aqueous
• Gel versus aqueous community acceptability study
2009-11
• Pilot program in four districts

Nepal: A living university for Chlorhexidine cord care
2009-11
• Coverage and compliance study
• CHX international meeting at Banke,
Nepalgunj
•
Approval from MoHP for national level scale up
• Government of Nepal with strong support of
JSI and other partners working together to scale up at national level

Nepal: A Living University for Chlorhexidine Cord
Care
• Providing technical and product Supply to neighboring Asian and several African countries for doing formative work and preparing to pilot
2012
Onwards
• Providing a learning platform to many international visitors
• Providing technical support to other implementing partners

Completed and Active Districts: 41
Planned: Entire Country (75 districts)
Impact

Communitybased programs
Misoprostol
Program
Chlorhexidine integration into ongoing programs
Health Facility
Delivery
Skilled Birth
Attendant
Training
Success through Integration
14

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
Partners and professional organisation involvement since beginning to scaling up
Nepal – member of global Chlorhexidine working group
15

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

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