Scaling up Chlorhexidine gel for umbilical cord care in Nigeria Systematically studying and implementing a scale-up effort Jenna Wright, MPH Broad Branch Associates / Maternal and Child Survival Program December 5, 2017 Olayinka Umar-Farouk, MD, MBA Save the Children / Maternal and Children Survival Program Arlington, VA Jim Ricca, MD, MPH Jhpiego / Maternal and Child Survival Program
Contents a) Background b) Study objective, methods and results c) Application of results
The Nigerian government seeks to scale up utilization of Chlorhexidine gel to reduce umbilical cord infections that lead to newborn sepsis and death Utilization of 4% Chlorhexidine gel (CHX) will increase to 52% after the fifth Vision year of national scale-up, saving up to 55,000 newborn lives What & Who: 1. Application of CHX to the newborn’s umbilical stump once a day for 7 days, starting within 90 minutes of birth, for all births 2. First application by the birth attendant (skilled birth attendant, traditional birth attendant or community health worker); remaining applications by the client Intervention description 3. Client counseling on correct application and general cord care Where: All birth settings (health facilities, community). Supplied through both public and private delivery channels
MCSP assists the Nigerian government expand service delivery and institutionalize supports for the intervention Pathway from Innovation to Sustainable Impact at Scale Reference: MCSP Stages of Innovation, Descriptions and Guidance (based on USAID Innovation to Impact, 2015)
Study objective: identify barriers to service expansion and institutionalization Assess relevant and actionable CFIR constructs within three domains 1. Intervention characteristics 2. Outer setting 3. Inner setting
We collected ordinal qualitative data from national, state and external participants using two instruments Readiness for Organizational Change tool Source: Holt DT et al. Readiness for Organizational Change: The Systematic Development of a Scale. Journal of Applied Behavioral Science 2007; 43; 232 Intervention scalability assessment Modified from : Cooley L et. al. Scaling Up –– From Vision to Large-Scale Change: A Management Framework for Practitioners. Management Sciences International, 2012.
Key barriers related to intervention characteristics CFIR construct Barrier Relative Perception that CHX does not hold a relative advantage advantage over methylated spirits or dry cord care for facility- based births Investment costs Concerns among domestic manufacturers that demand will not match supply and pay off their investment Certain clients in most need of CHX cannot afford to buy the product through private distribution outlets
Key barriers in the outer setting CFIR construct Barrier Cosmopolitanism Federal Ministry of Health (FMOH) has limited power to drive implementation at state level Government actors have limited experience with and capacity to scale interventions within private channels External policy & Many decision makers need to be involved in agreeing incentives to adoption and management of the intervention
Key barriers in the inner setting (1) CFIR construct Barrier Networks & Lack of routine mechanism for reporting and tracking Communication CHX availability and utilization Culture Perception among some policymakers and health workers that encouraging CHX use by traditional birth attendants sends the wrong signal (since facility-based birth is a national priority) Certain traditions in the community (traditional cord care management by elder family members, traditional naming ceremonies) may be affected by the intervention
Key barriers in the inner setting (2) CFIR construct Barrier Implementation Less perception of change efficacy among national level respondents (FMOH) than among respondents from states or partners climate I do not anticipate any Key: problems adjusting to the Strongly Disagree Agree Strongly work I will have when this disagree Agree change is adopted 1 2 3 4 4.0 My past experiences make I think I can do all the tasks 3.0 me confident that I will be that will be required when able to perform successfully we change 2.0 after this change is made 1.0 When I set my mind to it, I When we implement this can learn everything that change, I feel I can handle it will be required when this with ease change is adopted Federal (avg; N=6) I have the skills that are State (avg; N=5) needed to make this change Partner (avg; N=8) work
Key barriers in the inner setting (3) CFIR construct Barrier Readiness for Less strong management support for the intervention Implementation among government than among partners Key: Our senior leaders have Strongly Disagree Agree Strongly encouraged all of us to disagree Agree embrace this change 1 2 3 4 4.0 [My organization's] top Management has sent a clear 3.0 decision makers have put all signal [my organization] is their support behind this going to change 2.0 change effort 1.0 I think we are spending the Every senior manager has right amount of time on this stressed the importance of this change given the senior change mangers want it implemented Federal (avg; N=6) This organization’s most senior State (avg; N=5) leader is committed to this Partner (avg; N=8) change
MCSP supports FMOH and states apply a systematic approach to scale-up that mitigates barriers Mitigation of intervention Mitigation of outer Mitigation of inner characteristics barriers setting barriers setting barriers -Develop and implement a -Support states form -Build leadership and staff communications and multi-stakeholder teams buy-in for the intervention outreach strategy and manage scale-up and the scale-up activities -Mobilize continuous -Support FMOH and states -Support implementers to resources and promote to adjust policies and use timely information to ongoing procurement processes (e.g. State adapt/adjust scale-up Essential Medicine List) activities -Develop a distribution strategy to improve access -Develop public-private partnerships
For more information, please visit www.mcsprogram.org This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. facebook.com/MCSPglobal twitter.com/MCSPglobal
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