Of the estimated 2.6 million newborns who died worldwide in 2015, 9 percent were in Pakistan.1 In 2016, an initiative to deliver a life-saving inexpensive drug called chlorhexidine (CHX) to all newborns in Pakistan was launched by the Pakistani Ministry of National Health Services, Regulation, and Coordination, CHX National Working Group, and USAID’s JSI-managed Health Systems Strengthening Component. This effort comprises one of the broadest coalitions I have seen in my 15 years working in development. It was also the first time that drug manufacturers, the Drug Regulatory Authority of Pakistan, and USAID worked together to improve health outcomes.
Why is this so important?
The newborn mortality rate in Pakistan has been high over the last three decades, and recent estimates show that approximately 1-in-20 Pakistani newborns will not survive his/her first month.2,3
Newborn infection is preventable but accounts for approximately 1-in-5 newborn deaths in Pakistan.1,3 CHX is a topical antiseptic that when applied to a newborn’s umbilical stump, reduces infection and death. The World Health Organization (WHO) has recommended CHX for cord care in areas where newborn mortality is high. In Pakistan, studies suggest that CHX has the potential to reduce the risk of umbilical cord infection by up to 42 percent, and the risk of newborn death by as much as 38 percent. 4
So why are so many Pakistani newborns still dying of infections?
Tradition calls for the use of surma, a lead-based concoction, on a newborn’s umbilical stump to prevent infection. But research indicates that placing surma (and other traditional remedies such as ash, oil, and cow dung) on umbilical stumps actually causes infection, rather than prevents it.
In 2014, national and provincial health departments and public and private stakeholders added CHX to Pakistan’s essential medicines list. Although this was an important advancement, it did little to overcome the systemic challenges to CHX availability and use. Before the Health Systems Strengthening Component (HSSC), there was no coordinated CHX effort, protocol, or production. Partners worked in limited geographic areas—silos, essentially—to deliver CHX.
In 2015, USAID recognized the need for a coordinating mechanism to scale up CHX nationally and tasked JSI’s HSSC to streamline efforts among the Ministry of National Health Services, Regulation, and Coordination, provincial health departments, private drug manufactures, and development partners. JSI’s HSSC led a systems-based approach to develop consensus on national scale-up policies, guidelines, and standardized roadmaps for CHX scale-up in all parts of Pakistan.
The CHX working group that HSSC coordinated has broken down traditional development efforts and built consensus among partners that historically have had competing agendas. The working group has gained provincial and national support for the scale-up of CHX, and full endorsement from WHO and UNICEF representatives. USAID has donated 2.1 million tubes of CHX to treat newborns until local production of CHX begins in October of 2017.
As the national CXH coordinator, I can’t help but feel optimistic. We have a strong coalition for CHX scale up, and if collaboration and synergy continue, we will see the long-overdue reduction of newborn death rates in Pakistan. That will be something to celebrate.
CHX national scale-up coalition partners:
- Ministry of National Health Services Regulations & Coordination
- Provincial health departments (Punjab, Sindh, Khyber Pakhtunkhwa, Baluchistan)
- Regional health departments (Gilgit-Baltistan, Azad Kashmir, Islamabad Capital Territory, Federally Administered Tribal Areas)
- Regulatory bodies (Drug Regulatory Authority of Pakistan, Pakistan Nursing Council, Pakistan Medical and Dental Council)
- Representative bodies (SOGP, PPA, PMA Society of Obstetricians and Gynaecologists)
- Development partners (USAID, UNICEF, WHO, UNFPA)
- Implementing partners (JSI/HSS, JHPIEGO/ MCHIP, Mercy Corps, Save the Children, USP, SHOPS)
- Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2015;385(9966):430– doi:10.1016/S0140-6736(14)61698–6.
- MEASURE DHS. STATcompiler: building tables with DHS DATA. 2015. http://legacy.statcompiler.com/start.cfm.
- National Institute of Population Studies (NIPS) [Pakistan] and MII. Pakistan Demographic and Health Survey 2006– https://dhsprogram.com/pubs/pdf/FR200/FR200.pdf. Published 2008.
- Soofi S, Cousens S, Imdad A, Bhutto N, Ali N, Bhutta ZA. Topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of Pakistan: a community-based, cluster-randomised trial. Lancet. 2012;379(9820):1029– doi:10.1016/S0140–6736(11)61877–1.
*Dr. Nadeem Hassan is the National CHX Coordinator of the Health Systems Strengthening Component of USAID’s MCH Program.