Most countries have had steady reduction in under-5 mortality. However, many countries, including Madagascar, have experienced smaller reductions in neonatal mortality. The causes of neonatal mortality have been well documented, with birth asphyxia, prematurity and infection the greatest contributors. Recent studies have demonstrated that that early application of 7.1% Chlorhexidine Digluconate (CHX) to the umbilical cord significantly reduces mortality. Thus, in settings with poor hygiene at birth, this simple intervention can help prevent sepsis and cord infections, and avert preventable deaths.
In Madagascar, child mortality remains high despite some improvements over the last decade. Neonatal mortality also declined, but currently represents 33% of all under-5 deaths. A contributing factor is the high rate of home deliveries (65%). Although there are no data on the proportion of infections linked to cord care, current traditional practices contribute to increase the risk of sepsis and umbilical infection.
A Madagascar technical working group that includes the Ministry of Health, JSI/Mahefa, JHPIEGO/MCHIP, PSI/M and UNICEF developed a protocol to introduce CHX for umbilical cord care as a pilot program in the district of Mahabo in western Madagascar. With funding from USAID and PATH, the pilot program was officially launched in September 2013. It will be formally evaluated in July 2014. However, in order to reach the 2015 objectives of mortality rates reduction and given the interests on CHX at global level, a costed scale-up plan needed to be developed. The document would serve as an advocacy tool for use with the MOH and potential donors.
The vision for this scale-up plan is:
“To achieve 80% coverage nationally for application of CHX immediately after birth for all deliveries using the most efficient, cost-effective and sustainable approach to ensure maximum impact on neonatal mortality.”
To achieve the vision described above, the plan includes three key objectives with strategies that define specific activities designed to achieve each objective:
- Establish CHX as the standard for cord care
- Ensure that CHX is available
- Ensure that CHX is used by health facility staff, ACs, and mothers for cord care management for all neonates
Ensuring that CHX is established as the standard for cord care
The plan will be used for advocacy at all levels—both to facilitate rapid inclusion in Government MNCH policies, and also to define and coordinate donor support.The introduction of CHX as the new standard of umbilical cord care may not require an extensive revision of all MNCH policies, strategies and other documents – which may take a lot of time. Whenever a revision is planned, it represents an opportunity for CHX to be included. Nonetheless, the plan recommends holding policy development workshops that will spur the process. Once the MOH has established CHX as the new standard of umbilical cord care, it needs to be disseminated to all levels beyond a simple ministerial note. To that end, the plan recommends dissemination meetings at national and regional levels.
A prerequisite to scaling-up is the registration of CHX and ensuring that the exact formulation and dosage for CHX used for cordcare is included in the list of commodities routinely procured by the CSBs.
Ensuring that CHX is available
In order to maximize availability, while fitting into the existing successful systems for commodity procurement and distribution, the plan recommends procurement and distribution through two channels—the existing Government essential drug system, and the social marketing approach. These two systems combined should allow for universal availability, particularly for mothers in remote areas who may also be the most vulnerable.
Both systems are based on users’ fees, thus it is recommended to establish a price and a system to address both affordability and sustainability of procurement/resupply.
Commodity needs were calculated based on expected pregnancies and were estimated at 2,147,200 CHX tubes for the 3-years scale-up plan . The amount needed for each system were estimated to be 40% through the public sector and 60% for the social marketing system—based on current estimates of facility use for delivery
Ensuring that CHX is used by health facility staff, ACs, and mothers for cord care management for all neonates
The scale-up involves a training of all health facility staff and at least 2ACs per fokontany . A standard cascade training model is recommended with the integration of a CHX training module into existing MNCH/IMCI activities or refresher trainings at all levels,
In order to ensure the highest level of awareness and to create an informed demand among mothers, female family members and health care workers, the plan also envisions an integrated social marketing BCC approach using the same communication materials developed for the pilot.
Monitoring progress with scaling up can be done through commodity outflow and records of neonates for which CHX is used. Those data can be provided by the existing MOH SIG provided CHX is included . However, these will not provide an accurate measure of actual use or true coverage which can only be assessed through a survey. Thus, the plan includes a population-based survey of regions having completed CHX introduction after Year 1 of scaling up. After that, CHX should be included in any national survey that covers a range of MNCH interventions such as theDHS or UNICEF MICS survey or other existing survey.
It will take time for Government policy and strategy to change and to generate adequate funding for national implementation. Thus, the plan envisions a phased-in approach, anticipating 3 years to achieve national implementation coverage. The budget for a 3-years scaling up was estimated at 3.125.841 USD. The plan estimates that 1/3 of regions will be introducing CHX in Year 1, however it will depend on the Government and implementing partner planning and budget schedules. For this reason, no specific regions were identified for each year of the scale-up plan. However, it is likely that partners will prefer to introduce CHX in regions where they have ongoing activities into which to integrate this new intervention.
The scale-up plan will be successful if there is a shared commitment to the vision, with all stakeholders committed to their role. It calls for donor coordination and advocacy on the part of the Government to secure funding to supplement the Government’s contribution for scaling up. Thus, it is recommended that the MOH/DSMER lead the process of scale up and oversee program implementation as appropriate.