JSI Helps Pakistan Introduce Chlorhexidine to Save Newborn Lives

Samira is eight and a half months pregnant and about to give birth in a remote village in rural Pakistan, accessible to the outside world only by small, canoe-type 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.

Given the research on CHX, Pakistan’s Ministry of National Health Services, Regulation and Coordination (MNHSR&C) requested assistance to create a sustainable system to introduce CHX to Pakistan and scale-up its use across the country 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 asked to assist the government with creating a system to support national scale-up of CHX. The first thing JSI did was to bring together relevant government agencies, professional and regulatory bodies, donors, implementing partners, and NGOs. Previously, all these different entities had been working independently on CHX initiatives. It was time to create a coordinated effort to formally introduce, into the health system, CHX for the prevention of cord infections.

Over a period of one year, JSI helped coordinate a series of working groups to create Pakistan’s first CHX policy and standard treatment guideline. The CHX policy was adopted in January 2016 and was guided by the research published in The Lancet. The policy states that CHX is to be used for all births, both those that occur in health facilities as well as in communities (women who give birth at home).

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. This means that provinces will be held accountable 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 Pakistan, LHWs are a key “bridge” for ensuring women who live far away 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 counsel new mothers to use it, is a critical part of scaling up CHX to reduce the country’s newborn mortality rate. The government of Pakistan successfully convened the right stakeholders to add 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 national scale-up strategy for CHX, which mandates that each province develop its own CHX scale-up strategy. So far, four provinces, Punjab, Sindh, KPK, and GB, have a scale-up strategy in place that includes training needs and an estimate of the amount of CHX needed for one year. The U.S. government, through USAID, has committed to provide 2.1 million doses of CHX for a gap year until CHX can be locally produced. Local production of CHX will, of course, increase its chances of becoming a sustainable intervention.

In Samira’s small village on a remote creek in rural Pakistan, the impact of the too-numerous-to-count technical working group meetings, policy debates and endorsements, lady health worker trainings, and provincial scale-up strategy meetings cannot be more profound: the impact is that her son, when born, will have a 38 percent greater chance of surviving.

And because the government of Pakistan chose a systemic approach, rather than a project approach, to scaling-up CHX nationally to prevent cord infections, the likelihood that Samira’s grandchildren will also benefit from having CHX applied to their umbilical cords is much higher.

With a national CHX policy and standard treatment guidelines in place, CHX included on the essential drug list, plans for local production of CHX gel right here in Pakistan, a standardized national training manual, and well-trained health workers and lady health workers, it is highly unlikely that this low-cost, high impact lifesaving intervention will peter out over time. CHX is here to stay in Pakistan, thanks to USAID and the strengthened health system able to support it.