1. Innovation in reducing neonatal death using Chlorhexidine in Nepal- a case study

2. Saving Lives at Birth a Grand Challenge for Development This is three year project to scale up use of Chlorhexidine at national level The project aim to reduce neo-natal death cased by infection by using Chlorhexidine immediate after cord cutting This in one of the innovation project under USAID health, science and technology. 2

3. The Nepal Context- Child Mortality Source: NDHS&NHSP* 3 Marked decline in infant and child mortality Less improvement with neonatal mortality and no change from 2006-2011

4. 3 – 4 children die every hour

5. 63% of deliveries occur at home

6. Child birth considered an impure and dirty process

7. Expansion of community-based neonatal care program Promote institutional delivery and Skilled Birth Attendant Nepal Context – Policy 7 Strategies to reduce neonatal mortality

8. Nepal policy for CHX used Chlorhexidine will be applied to each newborn irrespective of facility and home birth. Nepal is using single dose resume immediate after cord cutting as a part of essential newborn care followed by clean and dry cord care practices. CHX is not stand alone program it is integral part of essential newborn care. 8

9. Why Nepal Accepted Chlorhexidine Cord Care Addressing a problem with high population health burdenEfficacyLow costSimplicitySafetyAcceptabilityLow regulatory requirementsHealth system compatibilityScalabilityCommercial viability 9

10. 2007 1 st consultative meeting in Nepal 2008-09 Non-inferiority trial of CHX gel compared to aqueous Gel versus aqueous community acceptability study 2009-11 Pilot program in four districts Nepal: A Living University for Chlorhexidine Cord Care

11. 2009-11 Coverage and compliance study CHX international meeting at Banke, Nepalgunj Approval from MoHP for national level scale up Government of Nepal with strong support of JSI and other partners working together to scale up at national level Nepal: A living university for Chlorhexidine cord care

12. 2012 Onwards Providing technical and product Supply to neighboring Asian and several African countries for doing formative work and preparing to pilot Providing a learning platform to many international visitors Providing technical support to other implementing partners Nepal: A Living University for Chlorhexidine Cord Care

13. Impact

14. 14 Success through Integration Chlorhexidine integration into ongoing programs Community- based programs Health Facility Delivery Skilled Birth Attendant Training Misoprostol Program Chlorhexidine integration into ongoing programs

15. Key to Program Success in Nepal Benefit of conducting the first RCT in Nepal Government leadership since inception of the program Local manufacturer (Lomus Pharmaceutical) producing a good-quality product Partners and professional organisation involvement since beginning to scaling up Nepal – member of global Chlorhexidine working group 15

16. Supply of 7.1%w/v Chlorhexidine in Nepal 3 gram of 7.1% Chlorhexidine digluconate gel tube - Nepali brand name Kawach. Pictorial instruction inside box. Current price is Rs.18 ($0.23) for Government. Supply is ensured through the government logistics supply system. Job aid to counsel mother

17. Doll as a Interpersonal Communication Tool

18. Ensuring Sustainability Chlorhexidine added in Essential Drug List of Nepal Chlorhexidine cord care is a part of an essential newborn care Government of Nepal included Chlorhexidine procurement in multi-year procurement plan Included in routine health information system for recording and reporting

19. Thank you