Case
Teaching Notes
Supplementary Resources
Abstract
It is January 2017, and Nikki Tyler, market access advisor at the U.S. Agency for International Development’s Center for Accelerating Innovation and Impact, must recommend an actionable strategy for how to use the $10 million contributed by global donors and foundations to scale up the use of chlorhexidine in Nigeria. It was clear that chlorhexidine, a substance applied to newborns’ umbilical cord stumps to prevent infection, could reduce infant mortality significantly. However, changing behavior would be an enormous challenge. This case gives students an appreciation for the importance and complexity of global health issues, along with an understanding of key analytic techniques for approaching a complex market situation. Students quickly learn that there are no easy answers to encouraging chlorhexidine’s greater use. To develop a plan, it is essential to complete detailed analyses, study insights and motivations, and ultimately compare different possible solutions, considering efficiency and efficacy.
This case was prepared for inclusion in SAGE Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.
2023 Sage Publications, Inc. All Rights Reserved
Resources
Exhibit 1: Neonatal Mortality Rates in Selected Nations, 2015
| Country | Deaths Within First 28 Days of Life per 1,000 Live Births |
| Australia | 2 |
| Bangladesh | 23 |
| Botswana | 22 |
| Canada | 3 |
| Chad | 39 |
| Haiti | 25 |
| Japan | 1 |
| Nepal | 22 |
| Nigeria | 34 |
| Senegal | 21 |
| Swaziland | 14 |
| United States | 4 |
Source: The World Bank, “Mortality Rate, Neonatal (Per 1,000 Live Births),” http://data.worldbank.org/indicator/SH.DYN.NMRT (accessed January 12, 2017).
Exhibit 2: Top Causes of Neonatal Mortality in Nigeria
| Causes | % of Deaths Within First 28 Days of Life |
| Preterm birth complications | 32.9 |
| Intrapartu | 27.3 |
| Infection/sepsis | 20.6 |
| Pneumonia | 8.7 |
| Congenital abnormalities | 4.4 |
| Other conditions | 6.0 |
Source: Child Health Epidemiology Reference Group (CHERG), “Underlying Causes of Child Death,” http://cherg.org/projects/underlying_causes.html (accessed January 12, 2017).
Exhibit 3: Population, Birth, and Mortality Rates in Nigeria
| 2006 Population | Births | Neonatal Mortality, 2013 (Deaths per 1,000 Live Births) | Infant Mortality, 2013 (Deaths per 1,000 Live Births) | |
| National | 140,431,790 | 7,028,000 | 37 | 69 |
| Zone | ||||
| North Central | 20,339,956 | 999,000 | 35 | 66 |
| North East | 18,984,299 | 1,100,000 | 43 | 77 |
| North West | 35,915,467 | 2,206,000 | 44 | 89 |
| South East | 16,431,555 | 716,000 | 37 | 82 |
| South South | 21,044,081 | 840,000 | 32 | 58 |
| South West | 27,722,432 | 1,167,000 | 39 | 61 |
Sources: Nigeria Federal Ministry of Health, “Nigeria State Data Profiles: An Accountability Tool for Maternal Newborn and Child Health in Nigeria,” http://www.mamaye.org/sites/default/files/evidence/MoH%20NG_2014_Nigeria%20State%20Profiles.pdf (for 2006 population and number of births), and Nigeria National Population Commission, “Nigeria Demographic & Health Survey 2013,” Table 8.2, https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf (for neonatal and infant mortality).
Exhibit 4: Place of Delivery of Newborns in Nigeria (%)
| Public Health Facility | Private Health Facility | Total Health Facility | Home | |
| National | 22.6 | 13.2 | 35.8 | 63.1 |
| Zone | ||||
| North Central | 30.0 | 15.7 | 45.7 | 52.9 |
| North East | 18.4 | 1.2 | 19.6 | 79.3 |
| North West | 11.0 | 0.5 | 11.5 | 87.5 |
| South East | 33.9 | 44.2 | 78.1 | 19.9 |
| South South | 35.7 | 14.3 | 50.0 | 48.7 |
| South West | 35.4 | 39.6 | 75.0 | 24.2 |
Source: Nigeria National Population Commission, “Nigeria Demographic & Health Survey 2013,” Table 9.5, https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf.
Exhibit 5: ANC Visits
| % Attending at Least One Visit | % Attending at Least Four Visits | |||
| National | 64.4 | 50.7 | ||
| Zone | ||||
| North Central | 70.2 | 56.6 | ||
| North East | 51.8 | 39.5 | ||
| North West | 41.8 | 21.9 | ||
| South East | 91.5 | 80.5 | ||
| South South | 73.5 | 61.2 | ||
| South West | 90.8 | 84.9 | ||
Source: Nigeria National Population Commission, “Nigeria Demographic & Health Survey 2013,” Table 9.1, https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf.
Exhibit 6: Person Assisting Birth in Nigeria (%)
| Total Skilled Health Provider | Doctor | Nurse/Midwife | Traditional Birth Attendant | Relative/Other | None | |
| National | 38.1 | 10.2 | 27.9 | 22.0 | 25.0 | 13.4 |
| Zone | ||||||
| North Central | 46.5 | 12.4 | 34.1 | 3.6 | 35.4 | 6.5 |
| North East | 19.9 | 3.3 | 16.6 | 26.0 | 39.0 | 9.7 |
| North West | 12.3 | 3.5 | 8.8 | 34.0 | 23.6 | 27.8 |
| South East | 82.2 | 13.7 | 68.5 | 7.4 | 5.1 | 1.5 |
| South South | 55.4 | 13.7 | 41.6 | 29.7 | 9.6 | 1.8 |
| South West | 82.5 | 30.4 | 52.1 | 7.4 | 7.1 | 1.3 |
| Place of delivery | ||||||
| Facility | 95.8 | 27.4 | 68.4 | 0.4 | 0.3 | 0.1 |
| Home | 6.1 | 0.7 | 5.4 | 34.6 | 35.8 | 21.1 |
Source: Nigeria National Population Commission, “Nigeria Demographic & Health Survey 2013,” Table 9.7, https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf.
Exhibit 7: Type of Substance Applied on Stump, When a Substance Was Applied
| Substance Applied | % |
| Oil | 31 |
| Methylated spirits | 30 |
| Toothpaste | 13 |
| Ash | 8 |
| Ointment/powder | 7 |
| Detol | 4 |
| Animal dung | 2 |
| Other | 11 |
| Don’t know | 2 |
Source: Nigeria National Population Commission, “Nigeria Demographic & Health Survey 2013,” Figure 9.4, https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf.
Exhibit 8: Source of Information for Antenatal and Postnatal Care
| Source of Information | % |
| Doctor/nurse | 34 |
| Radio | 25 |
| TV | 19 |
| Female relative | 7 |
| Wife of religious head | 3 |
Source: PATH Market Research in four states: Kano, Nassarawa, Osun, and Cross Rivers, November 2014.
Exhibit 9: Cord Care Purchase Behavior: Timing
| Timing | % |
| Before delivery, during ANC | 44.2 |
| Before delivery, not during ANC | 24.8 |
| At time of delivery | 21.3 |
Source: PATH Market Research in four states: Kano, Nassarawa, Osun, and Cross Rivers, November 2014.
Exhibit 10: Cord Care Purchase Behavior: Place of Purchase
| Place of Purchase | % |
| PPMV/chemist | 39 |
| Market/shop | 23 |
| Pharmacy | 16 |
| Healthcare facility | 10 |
| Other | 12 |
Source: PATH Market Research in four states: Kano, Nassarawa, Osun, and Cross Rivers, November 2014.
Exhibit 11: The States of Nigeria, Listed by Zone
| Nigerian State | Zone |
| Benue | North Central |
| Kogi | North Central |
| Kwara | North Central |
| Nasarawa | North Central |
| Niger | North Central |
| Plateau | North Central |
| Federal Capital Territory | North Central |
| Adamawa | North East |
| Bauchi | North East |
| Borno | North East |
| Gombe | North East |
| Taraba | North East |
| Yobe | North East |
| Jigawa | North West |
| Kaduna | North West |
| Kano | North West |
| Katsina | North West |
| Kebbi | North West |
| Sokoto | North West |
| Zamfara | North West |
| Abia | South East |
| Anambra | South East |
| Ebonyi | South East |
| Enugu | South East |
| Imo | South East |
| Akwa Ibom | South South |
| Cross River | South South |
| Bayelsa | South South |
| Rivers | South South |
| Delta | South South |
| Edo | South South |
| Ekiti | South West |
| Lagos | South West |
| Ogun | South West |
| Ondo | South West |
| Osun | South West |
| Oyo | South West |
This case was prepared for inclusion in SAGE Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.
2023 Sage Publications, Inc. All Rights Reserved
