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JSI Helps Pakistan Introduce Chlorhexidine to Save Newborn Lives

Samira will soon give birth in a village in rural Pakistan that is accessible to the rest of the world only by small, canoe-like boats. When Samira gives birth, she will likely follow the local tradition of placing surma (a lead-based concoction) on her newborn’s umbilical stump to prevent infection.

However, research has shown that placing surma (and other traditional remedies such as ash, oil, and cow dung) on umbilical stumps can actually cause infection, rather than prevent it.

Pakistan has the third highest newborn mortality rate in the world and umbilical cord infections are the second leading cause of newborn deaths in the country. Over the last two decades, the newborn mortality rate has remained stagnant.

Research published in The Lancet in 2012, however, points to a low-cost, high-impact intervention that can lower Pakistan’s newborn mortality rate if taken to scale. The research, conducted by Pakistan’s Aga Khan University, JSI, and funded by USAID, showed that applying an antiseptic gel (called chlorhexidine or CHX) to a newborn’s umbilical stump within 24 hours after birth can reduce severe infection by 78 percent and deaths by 38 percent.

Pakistan’s Ministry of National Health Services, Regulation and Coordination (MNHSR&C) requested assistance to introduce and scale-up use of CHX in Pakistan so that mothers like Samira would have a proven method for protecting their babies against umbilical cord infections. JSI, as the implementer of the Health Systems Strengthening Component of USAID’s Maternal and Child Health Program in Pakistan, was the perfect candidate for the task.

The first thing JSI did was convene relevant government agencies, professional and regulatory bodies, donors, and implementing partners. Each of these stakeholders had been working on CHX initiatives independently, and it was high time for a coordinated effort. Over the course of a year, JSI helped organize a series of working groups, which developed Pakistan’s first CHX policy and standard treatment guidelines. The policy was informed by the research published in The Lancet and was formally adopted in 2016. It calls for CHX to be used for all births, whether at home or in health facilities.

In addition to the policy and standard treatment guideline, another aspect of creating a system to sustain the introduction of CHX to prevent cord infections was getting the drug included on the essential drug lists for all provinces and at the national level. Thanks to advocacy by development partners, the Government of Pakistan added CHX to the essential drug list. Now each province is responsible for ensuring a continual supply of CHX in all health facilities and communities.

With the introduction of a new drug, training health workers and community health workers, including Pakistan’s lady health workers (LHW), to prescribe and use the drug correctly was critical. Before the CHX policy was introduced, different partners were using different training manuals, tools, and monitoring and evaluation practices. To achieve national scale-up, there needed to be one approach to training Pakistan’s health cadres. Again, JSI and MNHSR&C brought together a working group made up of government, professional and regulatory bodies, and the donor community to develop and finalize a nationally-endorsed CHX training manual, tools, and job aids. The training manual was endorsed by MNHSR&C in May 2016.


In rural Pakistan, a lady health worker shows a mother, who gave birth at home, how to apply CHX to her newborn's umblical stump.

In Pakistan, LHWs help women who live far from health facilities get the health services they need. Because so many women in Pakistan deliver their babies at home, getting CHX into the hands of LHWs and training them to use it, and teach new mothers to use it, is a critical part of scaling up CHX to reduce the country’s newborn mortality rate. Accordingly, the government of Pakistan has added CHX training to the LHW training curriculum.

Scaling-up an intervention, even one as simple and low-cost as using CHX to prevent cord infection, requires a strategy, particularly in a country as large and complex as Pakistan. JSI helped develop Pakistan’s strategy, which mandates that each province develop its own CHX scale-up plan. So far, four provinces—Punjab, Sindh, KPK, and GB—have strategies that include training needs and estimate the amount of CHX needed for one year. USAID has committed to provide 2.1 million doses of CHX for a gap year until CHX can be locally produced, which will increase its chances of becoming a sustainable intervention.

In Samira’s village, the effects of countless technical working group meetings, policy debates and endorsements, and lady health worker trainings could not be more profound: when her child is born, his/her chances of survival will be 38 percent greater than before CHX was introduced. And because the government of Pakistan chose a systemic rather than a project approach to scaling-up CHX, the likelihood that Samira’s grandchildren will benefit from having CHX applied to their umbilical cords is much higher.