The Nigeria Health Watch team recently visited Bauchi State. We had been invited by USAID’s Targeted States High Impact Project (TSHIP). The programme’s purpose is to “increase the use of health services and strengthen health systems to be more responsive to the basic health needs of households in Bauchi and Sokoto States.” We went to see for ourselves the impact of two new medicines that many refer to as “game changers”, recently introduced into primary health care.
In Nigeria, there are states that have begun to take the health sector more seriously. Two of these states are Sokoto and Bauchi in Northern Nigeria. We visited Bauchi to better understand the impact of introducing two life-saving and cost-effective interventions; chlorhexidine and misoprostol. If you have not heard about these two medicines, this piece is for you. If you have, this piece is also for you.
Let us first consider some sobering facts about the health of people in Bauchi. Bauchi has a maternal mortality ratio of 1,500/100,000, which means that one in every 66 women dies during the process of giving birth. To put this in context, you have to consider that maternal mortality in Somalia is 1,000/100,000 and 460/100,000 in Afghanistan, which are both countries in war. The maternal mortality rate in Bauchi is 10 times worse than in the South West of Nigeria (165/100,000). In Bauchi, according to the 2013 NDHS, only 17% of women give birth in a health care facility. This is an important index to remember as it means that, if we recruited thousands of doctors and nurses and provided all the medicines needed in the primary health care centres in Bauchi, we would still reach only 17% of the population.
What are “chlorhexidine” and “misoprostol”?
What are these two interventions that many people seem never to have heard about that protect both mother and new-born child just after birth? Misoprostol is a single-dose, three-pill medicine taken orally during birth which protects the woman giving birth from bleeding. It has replaced an injection, oxytocin, which was previously the drug of choice in protecting women from bleeding after birth (post-partum haemorrhage). The second medicine, chlorhexidine, is an easy to use antiseptic gel that is applied to the newborn’s cord stump within an hour of birth to prevent infection. The gel replaces methylated spirit, vaseline, local oils and some other “remedies” too gruesome to mention here. When used together, in a period health professionals call the “golden hour”, these two medicines prevent many deaths.
Does chlorhexidine really work?
The evidence has been consistent, as more studies have been done, that chlorhexidine really does work. A pooled analysis of the studies in Nepal, Pakistan and Bangladesh showed a reduction in the risk of death by 23%, and, if we take into consideration all possible causes of death in neonates, a reduction of 18% was found, i.e. one in six neonatal deaths are averted. Very few interventions in public health can demonstrate an effect this large. Comparative studies on the effect of chlorhexidine in Nigeria are still lacking, as the use of the gel is still relatively new. The TSHIP project, however, may be a game changer. In 2013 Bauchi State estimated that its procurement of chlorhexidine and misoprostol would prevent up to 2,250 newborn deaths due to cord infection and up to 1,000 maternal deaths due to postpartum hemorrhage.
Are they suitable for our setting?
Yes, this is one of the strengths of both drugs. Ideally, both should be given in a primary health centre, but they can easily be administered by lay people in the community. While there are continuous efforts to increase the number of births in Bauchi health facilities, community volunteers and traditional birth attendants have been trained to advocate for and administer these drugs in the community. In Bauchi, we met with passionate volunteers and mothers who had benefited from the programme and become strong advocates for its use in their communities. These are supported by Ward Development Committees (WDC), who are actively involved in all decisions, as well as the traditional rulers in Bauchi. Everyone is involved in these two medicines, from the commissioner to the family.
Community Volunteers and the Emir of Dass
Do we have to import?
The amazing thing about chlorhexidine is that its introduction has led to the establishment of a whole new ecosystem. Initially, it was imported from Nepal, but, in the last two years, two local manufacturers have started production in Otta and Ilorin, with a capacity to meet Nigeria’s total demand and export to other countries. In Nigeria, the bulk procurement cost is estimated at N250.00.
What has the impact been?
In addition to the impact on health indicators, softer benefits of this project are the establishment of an active health research and ethics committee in Bauchi, the strengthening of over 300 ward development committees, the physical renovation of about 70 PHCs and the introduction of oral rehydration corners in most PHCs. Also a state drugs and commodities procurement agency has been established, and most importantly the state has significantly increased its health sector budgetary allocation.
Why have you never heard of it?
Well, it is new! The two medicines were introduced into Nigeria by USAID’s flagship programme, TSHIP, initially to Sokoto and then Bauchi. Their introduction to other states in Nigeria is now strongly recommended. Of the 36 states in Nigeria, representatives from 31 states have visited one of the two TSHIP states to learn more about the programme.
Are these medicines “game changers”?
They could well be, if there is the political will to deliver them to our mothers and babies. They have been proven to be cheap, safe and stable in extreme temperatures. WHO updated its guidelines in 2014 to include chlorhexidine, and the Nigerian Federal Ministry of Health is in the process of updating its own guidelines. These two medicines will save lives. The challenge, as with many commodities in the Nigerian health sector, is to deliver them to our patients. If there is any state that should put health at the top of its political agenda, it is Bauchi State.
The introduction of these two new medicines in Sokoto and Bauchi has been driven by the TSHIP programme, funded by USAID. The programme has run for five years from 2010 to 2015 and it is now closing out and being handed over to the states. There are obviously concerns about sustainability, but Bauchi State assures that it is fully committed to continuing the programme. We will be back to check, that much we promise.
These two medicines will only become game changers if we want them to be.
To learn more about the programme, click here.