Bangladesh: Chlorohexadine Uptake in Dhaka
Updated: Sep 2, 2019
Nimmi Ramanujam, PhD, Director
Jeff Moe, formerly a faculty member in the business school and more recently in the Duke Global Health Institute invited me to collaborate with him a Bass connections grant which is am aimed at ask at asking a question that involves faculty and student engagement from different disciplines and levels. The question he was posing was “What are the bottle necks in the broad distribution of chlorohexadine (CHX) for umbilical cord care” in low resource settings. This is a high priority challenge that the USAID is trying to tackle. When Jeff asked me to collaborate on this proposal, I was reluctant because first I did not know anything about CHX having spent most of my career working on cancer technology and second, I could not get excited by the notion of desk research to do a bottle neck analysis when inventing something in the lab seemed way more appealing to my interests. Jeff convinced me that there would be a good deal of problem solving and design and that my effort on this project would have to be minimal. Well I agreed and it turned out to be a very rewarding experience. Almost 10 students applied to the program with background ranging from nursing to engineering to business and Danny Hamrick came on board as a leader in global value chain analysis which turned out to be a critical element of this project. The Bass project involved two semesters of structured meetings much like in a classroom setting culminating in several visits to the country we were assigned to where we would do validation of our desk research. What was wonderful about the 8 am Tuesday meetings were not just the bagels and coffee but an open-ended discussion that brought together manufacturing, economics, policy and most importantly, culture. A technology or commodity is only effective if people actually want to use it! Oh and I forgot to mention security. That actually became a big component of which country we selected to work in. Initially Jeff wanted to work in Kenya since he is quite familiar with it but because of the instability there at the time we made the decision to move our focus to Bangladesh as recommended by the USAID. Bangladesh does fit the USAID criterion for the number of newborn deaths that qualify it as a beneficiary of CHX use for umbilical cord care. The students spent a substantial component of the spring semester preceding our trip to Bangladesh identifying and understanding the different barriers in the global value chain. For example, one bottleneck is the manufacturing process, which results in a price point that makes marginal profit but is still too high for local NGOs to purchase and include in their birthing kits. When possible the team also spoke to local stakeholders through phone and skype calls to verify their initial findings. The most exciting aspect of this project was to be in country to actually see how all of these findings came together in the actual environment in which it was to be used.
I was the last team member to arrive in Dhaka. The students arrived first followed by Jeff and myself. Both of us had to stay behind because of graduation commitments in the early part of May. My first impression of Dhaka when I landed was that of the India I knew when I was a little girl. There was limited modern infrastructure, and a fatigued and w orn appearance to the completely congested city. There were no clear signs particularly at roundabouts making getting in and out bit of a Russian roulette. The time I got in was during the end of the day traffic and the area of Banani in Dhaka where out hotel was, felt like a quiet respite away from the hustle and bustle of the city. There was a beautiful little body of water in the back of the hotel and the sound of evening prayers from the mosque was spiritual and calming.
Although my stay was relatively short (2days) it was packed with lots of activity. The day of course always had to start with a strong cup of good coffee. Jeff was kind to take me a couple of the mornings to a local barista where we were able to enjoy freshly brewed coffee before the hustle and bustle of the day started. Being on the quiet streets of Dhaka where all you could hear was the wheels of the little man drawn taxi was meditative. Jeff had befriended a taxi driver the first day he arrived and he became our regular guy for the week eager to make sure we got to our coffee reliably and safely. Because of the wear and t ear of pulling the taxi, the driver’s slipper broke the day before we left and Jeff gave him some money to get it fixed and the driver promptly showed up on the day of our departure displaying his redeemed sandals that Jeff had helped him get repaired.
Our meetings with the stakeholders started in earnest when I got there and so I was excited to be a part of those varied and stimulating interactions. Our meetings started with the head of Save the Children NGO, which is partnering with USAID to get home delivery kits to pregnant mothers and one of the very first points he made was that in Dhaka, the preference for wet cord care with CHX was with a liquid rather than a gel formulation, which is what the World Health Organization recommends. He also said that although the recommendation is to use the agent for 7 days, studies have shown that one day is more effective than 7 day use likely due to the fact that it is hard for women to be consistent with the use of CHX as instructed over a longer period of time and there is a greater chance for contamination. The other point he mentioned which made so much sense when he said it was that although cost of the home birthing kits with CHX was an important consideration, aesthetics of the kit were important, because whether one is rich or poor, aesthetics do matter and kits need to be appealing within that local culture.
To get a different perspective, we also visited with the NGO BRAC, which is a world renowned global leader in creating opportunities for the poor. We went to the impressive multi-story building, bordering on a slum and met with the group on food and nutrition on the 16th floor. It was one of the most impressive meetings in that I got to learn about the vertical structure of how the program permeates communities in poverty through a network of health workers that are drawn from the community and are empowered to change the lives of the people they are closest to, i.e. the members of their own community.
There are health care workers who provide education and empowerment and are able to effectively train individuals to take on new practices within a year. In fact, the team leader said that BRAC has such an effective advocacy process that they can change minds in one year! They also have community health workers who can provide basic health care and deliver babies. What they have been able to do through this model is help women who deliver at home (70% of births in Bangladesh are home births) have access to essential medicines and tools in home delivery kits that they sell at a modest price through their community health workers. These women get a portion of the sales and then when they come to assist with home births, the mothers are ready with the necessary supplies to ensure a safe delivery. Their home delivery kit was basic and far from attractive but they did not seem to have a problem of distributing it to mothers and their biggest bottle neck was the cost of CHX from the local manufacturer ACI, which they felt was at a price point that would make the home birthing kit affordable to the mothers. They wanted a solution where the cost of CHX was sufficiently low to allow NGOs such as themselves to be able to distribute it to mothers in communities where hospital births are not common. This brings me our discussion with the local manufacturer ACI. It was hard to get a meeting with the product manager as it just so happened that ACI was good through a training workshop on good manufacturing practices but late one evening, we are able to have him over to our hotel to discuss the manufacturing bottle necks. ACI decided to put the CHX solution in a bottle that looked much like a eye dropper dispenser. The most expensive component of it was a purple plastic screw on cap that was outsources from India. There were a number of reasons for the cap including the screw on feature, the color and the cap design which was intended for ease of handling and use. However, the cap itself was the bulk of the cost of goods of the CHX bottle and the volume was much greater than the amount needed for umbilical cord care. So there appeared to be plenty of room to cut down costs on that end so that it could be attractive to NGOs. However, ACI does have demand from the government at the current price point and therefore is manufacturing CHX solutions for the public sector. However, given that 70% of births are carried out at home, one wonders if there are the best of intentions because of this issue of price points and predominantly home births where CHX will have the intended impact in this country.
I was reflecting on these bottle necks as I was thinking of cervical cancer screening which is in some respects a more complex problem where the costs of health care delivery far exceed what women can afford and the prices may not be brought down sufficiently unless there is sufficient demand (volume) which can really only be done through appropriate advocacy. It made me realize how important this early analysis will be for any new intervention and I was grateful that I head learned about a process (even though only peripherally) that would be critically important to our cancer prevention endeavors.