Moving along the chlorhexidine implementation trajectory: Planning to scale-up

1. Better Cord Care Saves Babies' Lives: Mapping Chlorhexidine Introduction and Implementation Examples from Madagascar, Nepal and Nigeria

2. Planning Moving along the chlorhexidine implementation trajectory: Planning to scale-up Scale-up Introduction • Convene working group to coordinate implementation of plan • Establish governance platform, including lines of accountability • Develop guidelines and procedures to ensure adherence • Increase public awareness in the introduction of chlorhexidine • Strengthen supply chain system, building capacity of staff to manage products • Strengthen local supplier base • Link suppliers and other stakeholders with information about demand • Quantity, procure, and manage products • Strengthen service delivery system, building capacity of staff • Generate provider/client demand • Assess client satisfaction • Analyze existing environment, human resources, and systems • Determine needs and priorities • Advocate to ensure buy-in for introduction • Engage stakeholders in working group • Prepare implementation “roadmap” • Identify success metrics and establish monitoring &evaluation system • Get policy approval for introduction • Amend the essential drug list to include chlorhexidine • Design supply chain system • Identify supplier base • Identify customer needs through client acceptability study • Develop manufacturing specifications, quantify needs, and procure product • Design system for delivering services • Train service providers • Mobilize beneficiaries/community representatives Governance • Explore feasibility of and resources for scale-up • Decentralize decision making to facilitate innovations and system improvement • Publish experiences and proven strategies • Plan for national/subnational reviews • Facilitate study exchanges • Revise supply chain system, and build capacity of staff and supervisors nationally • Link local and external suppliers with new programs • Quantity, procure, and manage products • Revise service delivery system, and build capacity of staff and supervisors • Integrate chlorhexidine into existing work plans and programs (i.e., MNCH) Ongoing advocacy Products Services

3. Madagascar: Planning for introduction (1) Background and context for pilot introduction Steps in planning for pilot introduction • Baseline study conducted, which identifies information on current cord care practices • Pilot planned to introduce chlorhexidine gel in Mahabo district (Western region) • Chlorhexidine will be integrated into on-going program managing childhood illness and providing family planning and other services • Technical working group established to provide coordination of pilot activities (MOH provides overall technical leadership/coordination) • Product acceptability study and field testing of product name, logo packaging, and design (PSI) • Conduct trainings for health workers (MCHIP) and community health workers (CHW) (JSI) • Procure Chlorhexidine from manufacturer in Nepal (JSI) • Monitor the intervention at the community level (JSI) 1 2 3 Newborns like this child in Mahabo will soon be protected from sepsis when chlorhexidine is available in the district. 4 5

4. Madagascar: Moving towards implementation (2) First CHWs training, September 2013 Steps in implementation 1 • Conduct official launch of projectin Mahabo • Lobby and raise awareness of Chlorhexidine at regional and local levels • Train health workers and CHWs • Train referral providers • Adapt data collection tools (e.g., register, report form, booklet) • Put in place a field supervisor to overseeCHWs with NGOs implementing partners • Conduct quarterly field monitoring and annual assessment • Integrate misoprostol - chlorhexidine for community based service provision 2 3 4 5 Job aid for CHWs 6 7 8 On-going: Assessing the feasibility of scale-up

5. Nigeria: Introduction of chlorhexidine in Sokoto The context for introduction: Profile for Sokoto & Bauchi States Steps in introducing chlorhexidine in Sokoto • Conducted research to understand current practices, receptiveness, and user preferences • Undertook state and national advocacy/policy efforts to support Sokoto State Gov’t to launch chlorhexidine program • Added chlorhexidine to essential drug list at federal, state, and local government level • Designed and strengthened systems to deliver services and products • Brief 244 Ward Development Committees (WDC) in Sokoto • Train 440 community volunteers & 1220 drug keepers within 6 months • Incorporate into routine monitoring system • Procured chlorhexidinegel (4%) from Nepal; simultaneously built capacity for local production 1 2 3 4 After 12 months: 9.33% coverage in Sokoto 5 Target @ 80% coverage • Sokoto introduction efforts result in: • Government and community making a firm commitment to scale-up • 13 of 36 States being ready to introduce chlorhexidine References: National Demography & Health Survey (NDHS) 2008; Nigeria Bureau of Statistics, 2012; TSHIP Reports

6. Nepal: Achieving coverage at scale Activities required for scale-up Background and context • Preliminary studies on efficacy of product and community acceptability (gel versus Aqueous), show preference for gel • Pilot study in 4 districts to determine coverage and compliance in Nepal context proves successful • In 2011, Government of Nepal approves use of 4% chlorhexidine as part of essential newborn care Incorporate chlorhexidine into essential newborn care related program and packages Train all service providers and community health volunteers Include chlorhexidine in essential drug list and multi-year procurement plans Involve private sector to ensure quality supply of product Undertake BCC activities Include chlorhexidine activities in routine health management information system Engage active involvement of stakeholders throughout implementation process Conduct advocacy at different level and forums (professional societies and conferences) 1 2 3 4 Scale-up plan and progress Scale-up plan aims to bring chlorhexidine to newborns in at least 63 of 73 districts in over 3 years (2011 – 2013). Progress shown below: 5 6 7 8