From Nepal to Nigeria: Lessons in taking newborn health interventions to scale

Each year in Nigeria, more than 240,000 babies die in their first month of life, accounting for more than a quarter of all under-five deaths. Thirty percent of these deaths occur because of severe infections that are acquired soon after birth and during the first days of life, which is when babies are at most risk of dying.

Fortunately, we know most of these lives could be saved by improving hygiene, reducing exposure to life-threatening bacterial infections particularly in the first week of life, and by making antibiotics available to newborns who become sick. The Government of Nigeria has taken action to ensure no newborn dies from preventable causes.  Once such step is its commitment to introduce chlorhexidine for umbilical cord care on a national scale. This inexpensive and widely available antiseptic has been proven to dramatically reduce newborn mortality when applied to the baby’s umbilical cord soon after birth.

This video highlights the Nigeria delegation’s learning visit to Nepal to learn about the country’s Chlorhexidine for umbilical cord care program. 

A learning visit to Nepal

Considering that two-thirds of births take place at home in the absence of a qualified health worker, Nigeria is keen to introduce community-based approaches and interventions to prevent newborn infections. This is why last month, a delegation of 11 of Nigeria’s most dedicated stakeholders traveled to Nepal, a country that has made remarkable progress in implementing chlorhexidine at the community level. Not only has Nepal made strides in ensuring the antiseptic is widely available in health facilities, it has also provided access to mothers and newborns in remote areas through community-based distribution through their Female Community Health Volunteer program (FCHVs).

The delegation sought to learn from Nepal’s successes and challenges in implementing chlorhexidine in order to provide further guidance for those involved withthe wide-scale introduction and implementation of chlorhexidine for newborn cord care in Nigeria. The team included members from the Federal Ministry of Health, the National Primary Health Care Development Agency (NPHCDA), the National Agency for Food and Drug Administration and Control (NAFDAC), Jigawa State Ministry of Health, the State Primary Health Care Development Agency (from Jigawa and Katsina states), the Nigerian Society for Neonatal Medicine (NISONM), and Save the Children.

Members of the Nigerian delegation including Dr. Kayode Afolabi, Head of the Child Health Division at the Federal Ministry of Health in Nigeria (far left), observe the application of chlorhexidine for umbilical cord care at the Kohalpur medical hospital in Banke district, Nepal. Photo: Narendra Pradhan for Save the Children

A look at Nepal’s delivery mechanisms for chlorhexidine

After arriving in Nepal, we spent the first few days in the capital city of Kathmandu interacting with Nepali stakeholders, including those from Nepal’s Ministry of Health and Population, Save the Children – Nepal, and JSI. These initial meetings gave us a better understanding of the health care system in Nepal, and they also gave us the opportunity to discuss the facilitators and barriers of different delivery strategies, ranging from antenatal and delivery care, to community health workers. In addition, we were able to share with the Nepali stakeholders information on Nigeria’s health care system, including the IMNCH strategy and the Saving One Million Lives Initiative.

We then departed for Banke District, which is in the southwestern part of the country near the Indian border. Upon arriving, the director of the District Public Health Office of Banke gave us an overview of the health system and the remarkable progress they have made in ensuring chlorhexidine is available to all mothers and newborns across the district. The following day, we visited a privately-funded hospital that uses chlorhexidine for clean cord care. The busy referral hospital is also a medical college, where maternal and newborn care services are offered at no charge to women and their families.

One of the highlights of our time in Banke was meeting a few FCHVs.  Prior to the visit, we knew that Nepal has had internationally recognized success in achieving positive health outcomes using this extensive network of volunteers. It was when we were in rural Banke, however, that we realized how big of a role they play. Not only do they provide chlorhexidine to mothers a month before they give birth during routine antenatal visits, they also visit mothers soon after they give birth to ensure that the mother and the baby are healthy. The commitment and motivation of FCHVs is remarkable, and Nepal’s efforts to sustain this cadre are commendable. While health volunteers in Nigeria have a high attrition rate, Nepali FCHVs are remarkably committed to volunteerism—some of the FCHVs we met have been assisting their communities for more than 15 years! We hope to use what we learned in Nepal to inform Nigeria’s system of community health volunteers and the new village health workers scheme recently inaugurated.

After returning to Kathmandu, we visited Lomus Pharmaceuticals, the company that has developed the product for Nepal and now also supplies to other countries, including Nigeria. Since chlorhexidine is locally manufactured, Nepal is able to provide a continuous supply for only about 0.23 USD per single-use application. By interacting with workers at Lomus, we were able to explore issues around drug policy regulation, manufacturing, supply chain management, and social marketing of health commodities.

A discussion with Nepal’s Female Community Health Volunteers Sita Yadav and Sharda Oli (pictured in their blueuniforms) and new mothers Chandra Pun and Irada Shahi, both of whom received chlorhexidine during antenatal check-ups. Kamdi, Banke district, Nepal. Photo: Narendra Pradhan for Save the Children

Next Steps

To date, two states in Nigeria – Sokoto and Bauchi – have already initiated implementation of chlorhexidine, supported by partners including USAID’s TSHIP program, the Bill & Melinda Gates Foundation, and JSI. The learning visit also provided a forum for our stakeholders to compare learning emerging from Sokoto and Bauchi, and inform Nigeria’s plans to roll out chlorhexidine within a broader community health program. Furthermore, the availability of chlorhexidine will greatly facilitate progress towards Nigeria’s Saving One Million Lives Agenda, the Every Newborn agenda, and the UN Commission on Lifesaving Commodities, which is co-chaired by the president of Nigeria.

Back at home, the policies are mostly in place; what is needed now is action at state and local level to increase coverage and quality of life-saving interventions, while closing the equity gap for the poorest families. We seek to extend the collaboration we made in Nepal among federal, state, and non-government stakeholders to Nigeria as a whole. Such collaboration will include targeted meetings with high-level federal and state officials to revise and finalize Nigeria’s guidelines for chlorhexidine application, formulizing arrangements for the production and distribution of chlorhexidine, state and national-level advocacy, and other efforts that will result in an effective nation-wide chlorhexidine program.

Mothers in Nepal are benefitting from improved care, as evidenced from my conversation with mothers in the postnatal ward at Kohalpur medical hospital in Banke. Photo: Narendra Pradhan for Save the Children

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