title: Analysis of misoprostol and chlorhexidine policy gains in Pakistan: the advocacy experience of Mercy Corps Pakistan.
abstract: While Pakistan has made progress toward achieving Millennium Development Goal 5 for maternal health, it is unlikely to achieve the target; further, it is also not on track for Millennium Development Goal 4 regarding child health. Two low-cost, temperature stable and life-saving drugs, misoprostol and chlorhexidine, can respectively avert maternal and newborn deaths, and are particularly pertinent for poor and marginalized areas which bear the brunt of maternal and newborn deaths in Pakistan. In response, Mercy Corps led focused advocacy efforts to promote changes in policies, protocols, and regulatory environments for misoprostol (2012-2014) and for chlorhexidine (2014). These short-duration advocacy projects facilitated significant policy gains, such as inclusion of misoprostol and chlorhexidine into province-specific essential drug lists, development and endorsement of clinical protocols for the two drugs by provincial health departments, inclusion of misoprostol into pre-service training curriculum for several health cadres, and application for registration of chlorhexidine (at the concentration required for newborn care) by two pharmaceutical companies. These results were achieved by a consultative and evidence-based process which generated feedback from community members, program implementers, and policymakers, and ultimately put the government in the driver's seat to facilitate change. Community Action Dialogue forums were linked with provincial-level Technical Working Groups and Provincial Steering Committees, who passed on endorsed recommendations to the Health Secretary. The key factors which facilitated change were the identification of champions within the provincial health departments, prioritization of relationship building and follow-up, focus on concrete advocacy aims rather than broad objectives, and the use of multi-stakeholder forums to secure an enabling environment for the policy changes to take root. While these advocacy initiatives resulted in significant policy changes in Pakistan's devolved health system, to ensure these policy changes have an impact on health outcomes, Pakistan should focus on the scale-up of appropriate use of chlorhexidine and misoprostol. Further, future policy initiatives in Pakistan should make use of similar multi-stakeholder policy forums, while ensuring a third party to facilitate the process so that civil society and community voices are not lost in the policy development discussion.
authors.affiliation: Policy Strategy & Planning Unit, Department of Health, Government of Punjab, Lahore, Pakistan. z_sarwar@hotmail.co.uk.
authors.forename: Zahida
authors.initials: Z
authors.lastname: Sarwar
authors.affiliation: Mercy Corps Pakistan, Islamabad, Pakistan. andrea.cutherell@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Cutherell
authors.affiliation: Mercy Corps Pakistan, Islamabad, Pakistan. anoor@pk.mercycorps.org.
authors.forename: Arif
authors.initials: A
authors.lastname: Noor
authors.affiliation: Mercy Corps Pakistan, Islamabad, Pakistan. f.naureen@gmail.com.
authors.forename: Farah
authors.initials: F
authors.lastname: Naureen
authors.affiliation: Mercy Corps, Washington, DC, USA. jnorman@hq.mercycorps.org.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Norman
mesh_terms: D000328:Adult; D000891:Anti-Infective Agents, Local / Q000627:therapeutic use; D002648:Child; D000067576:Child Health; D002675:Child, Preschool; D002710:Chlorhexidine / Q000627:therapeutic use*; D003256:Community Participation; D003254:Consumer Advocacy; D003906:Developing Countries; D006291:Health Policy; D006801:Humans; D000068104:Infant Health; D007231:Infant, Newborn; D063130:Maternal Death / Q000517:prevention & control*; D000068097:Maternal Health; D000068101:Maternal-Child Health Services; D016595:Misoprostol / Q000627:therapeutic use*; D009938:Organizations; D010120:Oxytocics / Q000627:therapeutic use; D010154:Pakistan; D066087:Perinatal Death / Q000517:prevention & control*; D012959:Socioeconomic Factors
chemical_list: D000891:Anti-Infective Agents, Local; D010120:Oxytocics; D016595:Misoprostol; D002710:Chlorhexidine