Case Study of Nigerias experience scaling up chlorhexidine use in newborns, 2015-2021: analysis of implementation of actions to support scale-up and progress towards institutionalization

BackgroundApplication of chlorhexidine (CHX) to the umbilical stump is an evidence-based intervention to prevent newborn infections. Successful pilot experiences led the Nigeria Federal Ministry of Health (FMoH) to launch a national, five-year scale-up strategy in 2016. In this case study, we analyze the implementation of national and state-level scale-up actions described and mandated in the national strategy and progress toward institutionalizing CHX within the routine health system using the WHO building blocks framework. MethodsWe conducted a mixed methods case study that consisted of interviews with key informants after the midline of the national strategy; focus groups of well-informed senior stakeholders at midline and endline of the strategy to assess the level of institutionalization achieved and the status of implementation of national-level scale-up actions described in the national strategy; and online surveys of state reproductive health coordinators (SRHCs) at midline and endline about implementation of state-level actions and the extent of international partner support. ResultsInstitutionalization of CHX progressed steadily across all health system building blocks. Most rapid progress was in governance, followed by human resources and supply chain management, with slower progress on the health information system. The building block lagging most was financing, with continued dependence on external funding. Most but not all national-level actions were implemented as planned. There was wide variation in the implementation of state-level actions included in the national plan. Discussion and ConclusionNigeria has made substantial progress in institutionalizing CHX across the health system building blocks. In terms of implementation of planned state-level scale-up actions, wide variation points to the need for more sustained and coordinated action, and the importance of actively managing this coordination. At national level, as Nigeria continues in the second phase of its scale-up efforts, the FMoH needs to strengthen coordination and financing.