Journey to Scale: Five Things We Learned from Implementing the Chlorhexidine Cord Care Program in Nepal
Originally posted on JSI's The Pump
New technologies and innovations are quickly changing the way we approach maternal and newborn health promotion, prevention, and treatment. However, taking these innovations to scale still presents a challenge.
With catalytic funding from Saving Lives at Birth, JSI has worked closely with the government of Nepal, and other partners, to scale up the use of Chlorhexidine (CHX) to reduce neonatal mortality due to infections. JSI recently hosted five Saving Lives at Birth transition-to-scale grantees to share insights into why the CHX program in Nepal has been so successful.
Government officials and Saving Lives at Birth innovators learn about PharmaChk, a portable device that can quickly measure active ingredient concentration and drug dissolution to screen for substandard medicines.
We discussed the nine elements of scale-up with the grantees. These include the use of evidence for policy, coordination mechanisms, licensing and manufacturing product, commodities and distribution mechanisms, capacity building, implementation approach or integration, social and behavior change communication, monitoring and evaluation, and most important, partnership. We also shared the top five lessons that we’ve learned about taking innovations to scale:
1. Use evidence to inform policy: When the CHX program was launched in Nepal, neonatal mortality was stagnant at 33 per 1000 live births between the 2006 and 2011 Demographic Health Surveys. The Nepal Nutrition Intervention Project-Sarlahi/Johns Hopkins University, Bloomberg School of Public Health had also just conducted the first community-based Randomized Cluster Trial on the use of CHX that showed that it reduced neonatal mortality by 34 percent and prevented severe omphalitis by 75 percent. These findings were later validated by studies in Bangladesh and Pakistan. Given the existing challenges, and the emergence of new data, the Government of Nepal was receptive to new interventions that could dramatically impact neonatal mortality.
2. Engage key stakeholders in policy design and promote government stewardship: Engaging the correct stakeholders in the policy/program design helps to build ownership and encourage sustainability. We worked with the Family Health Division within the Department of Health Services to convene a technical working group comprised of representatives from government, development partners, academia, professional societies, and the private sector. The working group provided guidance on the implementation process. It also had oversight of early studies to confirm preferred formulation, acceptability among users, and the initial pilots. The group continued to guide the program for the subsequent years of implementation. By including the private sector in the technical working group, we were able to demonstrate the potential health impacts of CHX and convince them to produce the commodity locally despite low profit margins. CHX produced in Nepal is now being supplied to 10 countries.
3. Integrate innovations into existing channels: Based on buy-in from key stakeholders, CHX was integrated into existing government maternal, newborn, and child health programs such as the Community-Based Newborn Care Program and use of Misoprostol for prevention of postpartum hemorrhage. As a key intervention for improving newborn health, CHX has been integrated into other policy documents including Nepal’s Every Newborn Action Plan. The Ministry of Health has also included CHX in the essential medicine list, the training curriculum for skilled birth attendants and auxiliary nurse midwives, and initiated a long-term procurement plan for CHX that began in 2016.
Female Community Health Volunteers teach Saving Lives at Birth innovators how they educate mothers and families about the benefits of chlorhexidine, and how to apply the life-saving commodity.
4. Information and knowledge management is key to monitoring and evaluation: Without good data on CHX use and availability, we would not be able to generate evidence to support program management. In collaboration with government colleagues, we integrated CHX into the National Health Management Information System, which allowed health workers to record and report the use of CHX at the community and health facility levels. Nepal’s extensive network of Female Community Health Volunteers was instrumental in collecting and reporting data on the use of CHX at home births, which still account for around 50 percent of births in the country. CHX is also included in the government’s Logistics Management Information System, which provides information on the availability of CHX at service delivery sites throughout the country. This allowed us to monitor CHX stock on a quarterly basis and address stock outs at the district and sub-district levels. Apart from routine health information management systems, CHX indicators are also included in various population surveys including the Demographic and Health Survey, Multiple Cluster Indicator Survey, and Health Facility Surveys.
5. Engage the community through Social Behavior Change Communications: Social behavior change communication was an essential component of the Nepal CHX program. As in most countries, Nepal is home to different languages, cultures, and practices, so interventions were tailored for local and regional audiences. We used a combination of national radio and television advertisements, promotion on local FM stations, and community-level education by equipping Female Community Health Volunteers with job aids, training dolls, and posters to help them counsel women and families within their catchment areas on the proper use of CHX.
The Nepal experience has generated many lessons that JSI, in partnership with the Nepalese government, have used to provide guidance and technical assistance to governments around the world that are interested in the use of CHX. We have shared training manuals, job aids, sample behavior change communication strategies, and reporting tools with nearly 20 countries. This has led to implementation of CHX programs in Bangladesh, Democratic Republic of the Congo, Ethiopia, Kenya, Liberia, Madagascar, Malawi, Mozambique, Niger, Nigeria, Pakistan, Senegal, and Uganda.