Chlorhexidine Scale-Up in Nepal — Reflecting on Achievements and Planning for the Future

August 25th, 2017 | Viewpoint

A Female Community Health Volunteer displays a tube of chlorhexidine gel. Photo Credit: Pushkar Khanal, JSI.

On July 28, 2017, JSI brought together newborn health advocates and experts from around the world to discuss global best practices for scaling up the use of chlorhexidine and lessons learned from the JSI-led Chlorhexidine Newborn Cord Care Program (JSI/CNCP)—the first global effort to introduce chlorhexidine for newborn cord care as a low-cost intervention to prevent newborn infection. By the end of September 2017, the JSI/CNCP program, in collaboration with the Nepal government and local partners, will have scaled up the use of chlorhexidine in all public and major private health facilities throughout the country’s 75 districts. To date, the program has reached every district and covers 95% of Nepal’s total population.

Learning from and Building on Nepal’s Experience

As the first country to achieve nationwide scale-up of chlorhexidine for newborn cord care, Nepal has become a “living university” for the world. Its experience provides crucial evidence, lessons learned, and resources for other countries seeking to introduce or scale-up chlorhexidine. This event distilled and shared these insights and resources. A few best practices emerged during the discussion, including:

1. Government Ownership and Integration

Dr. Bikash Lamichhane, Director, Child Health Division, from Nepal’s Ministry of Health, presents the history of CNCP and components that ensure sustainability. Photo Credit: Nkem Wellington, JSI.

To ensure that program gains can be sustained, it is crucial for partners to work closely with the government from program inception, providing technical assistance for procurement, monitoring, and quality improvement so that the government can continue to implement the program. JSI/CNCP worked with the Government of Nepal to integrate chlorhexidine within existing government programs and systems, promoting rapid scale-up and sustainability. During the event, Dr. Bikash Lamichhane from Nepal’s Ministry of Health discussed the impetus for chlorhexidine introduction in Nepal and the government’s plans to continue program implementation. In his remarks, he noted the importance of integration, saying “once we realized that [chlorhexidine] was crucial to reduce neonatal deaths, we introduced it and then we integrated it.”

“Nationwide scale-up & sustainability of an innovation is possible by integrating within the existing health system.” – Leela Khanal, JSI/CNCP Project Director.

2. Private Sector Partnership

Engaging the private sector was crucial for successful chlorhexidine introduction and scale-up in Nepal. Lomus Pharmaceuticals, Nepal’s largest pharmaceutical company, was a key private sector partner for JSI/CNCP, creating and testing the first 4% chlorhexidine gel formulation globally. The availability of a quality product through in-country production reinforced the program’s sustainability.

A partnership with private hospitals was also essential to reach every newborn in Nepal. Dr. Suman Raj Tamrakar of Dhulikhel Hospital, a public-private partnership community hospital in Nepal, presented his hospital’s efforts to introduce chlorhexidine. Dhulikhel Hospital has achieved 100% chlorhexidine compliance for newborns in the hospital, reaching over 10,000 of them. It also serves as a learning site, hosting 16 groups of international visitors to share the hospital’s experiences in chlorhexidine implementation and public-private collaboration.

3. Demand Generation

Social and behavior change communication (SBCC) interventions and targeted approaches should be included in initial program design to reach all newborns and their caregivers. JSI’s Leela Khanal shared crucial lessons learned from JSI/CNCP, including the program’s efforts to reach newborns in hard-to-reach areas. To maintain high coverage in rural areas and for home births, the project distributed chlorhexidine to pregnant women through health facilities and Female Community Health Volunteers. It also led targeted SBCC campaigns to promote chlorhexidine use. When JSI/CNCP learned that 20% of women did not have access to information about chlorhexidine, the project began targeted SBCC activities and community outreach, including community orientations and local leader mobilization, to reach areas where mass media access is limited.

A Female Community Health Volunteer holds a community orientation as part of SBCC efforts to promote chlorhexidine use in hard-to-reach areas. Photo Credit: Maan Subba, JSI.

The Future of Chlorhexidine Programming

Reaching every child with a lifesaving intervention is incredibly challenging. This program, which has achieved 95% population coverage, shows that scale-up is possible. To continue to save newborn lives, this low-cost, evidence-based intervention should be integrated into the health system at scale.

International visitors observe Female Community Health Volunteers demonstrating how they wash their hands thoroughly before applying chlorhexidine. Photo Credit: Pushkar Khanal, JSI.

In her closing remarks, USAID’s Dr. Lily Kak gave a call to action for the global newborn health community to mainstream chlorhexidine into programs around the world, incorporating learning from Nepal’s experience. To date, JSI has supported chlorhexidine introduction and scale-up in Ethiopia, Nepal, Nigeria, Madagascar, and Pakistan, bringing this life-saving intervention to newborns around the world. As Dr. Tamrakar said, “Chlorhexidine comes in a small 3-gram tube, but this small intervention creates big change.”

Written by Leela Khanal and Sarah Cunningham

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