{"id":40015,"date":"2024-11-25T11:29:30","date_gmt":"2024-11-25T11:29:30","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjgh\/?p=40015"},"modified":"2024-11-25T11:29:30","modified_gmt":"2024-11-25T11:29:30","slug":"expanding-ors-zinc-coverage-for-childhood-diarrhoea-is-institutionalising-free-distribution-the-answer","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjgh\/2024\/11\/25\/expanding-ors-zinc-coverage-for-childhood-diarrhoea-is-institutionalising-free-distribution-the-answer\/","title":{"rendered":"Expanding ORS\/zinc coverage for childhood diarrhoea: is institutionalising free distribution the answer?"},"content":{"rendered":"

 <\/p>\n

As we commemorate the twentieth anniversary<\/a> of the 2004 global recommendation of oral rehydration salts and zinc sulphate (ORSZ) as the standard treatment for diarrhoea, sub-Saharan Africa continues to face persistently low coverage rates<\/a> (19%). Diarrhoea remains a leading cause of child mortality, responsible for approximately 9% of all deaths among children under age 5. This equates to 444,000 deaths annually or 1,200 deaths each day<\/a>.<\/p>\n

While efforts to increase ORSZ coverage have shown promise<\/a>, the rate of progress in improving coverage of the combination therapy has been slow, rising at 2.5 percentage points per year<\/a> on average, leaving significant room for accelerated progress.<\/p>\n

A randomised controlled trial in Uganda<\/a> comparing three home delivery models of ORSZ distribution by community health workers found that pre-emptive, free distribution was the most cost-effective approach. Another study<\/a> noted that countries with \u201csustained successes\u201d in scaling ORS (Sierra Leone, Guyana, Malawi, and Bangladesh) focused on community\u2013level delivery, promoted ORS through health worker communications and mass media, provided ORS free of charge in the public sector and had secure supply of the product.<\/p>\n

If we accept that an established, cost-effective approach to scaling in some low- and middle-income countries is to provide ORSZ free of charge, we must explore how best to achieve this sustainably and who pays. In other words, we need to establish how best to institutionalise the free distribution of ORSZ. This would require a move away from project-based efforts to increase ORSZ coverage to a local focus on systems change<\/a>. Given that the benefits of free distribution accrue to society and the economy as a whole, it will fall to governments to lead this change and fund it in the long term. This would need to be presented as a high-return investment opportunity rather than a drain on the national budget. We have the evidence to make this case<\/a>.<\/p>\n

But it\u2019s not just about who pays. How do health ministries switch to free ORSZ distribution in a way that maximises the benefit to a country as a whole? Do donors have a catalysing role in this scenario?<\/p>\n

If ORSZ is to be free, it needs to be sustainably free, ideally with the funds spent by the government, as an anchor client, on the procurement of ORSZ going into the local economy. This points to the crucial need for local manufacturing<\/a>, which in turn would require donors to focus on strengthening the local <\/a>value-chain for ORSZ<\/a>, including support for Good Manufacturing Practice, moving away from imported products. Add-on benefits include: strengthening of local systems, less environmental impact, less risk of supply shortages, and \u00a0opportunities for designs<\/a> to be better tailored to local contexts<\/a>, including co-packaging of ORSZ. A further important consideration is how government-funded free ORSZ sits alongside commercial products on the local market. The free offer should be distinct from what is already available commercially, so that they can co-exist and ideally reinforce each other.<\/p>\n

This may sound aspirational, but Zambia offers an example of this approach working in practice. A local public\/private partnership contributed to an increase in ORSZ coverage from less than 1% (2012)<\/a> to 34% (2018)<\/a>. \u00a0Notably, since 2018, local manufacture and distribution has further increased<\/a>, powered by local public and private systems rather than by short-term projects and external actors. This is despite serious disruption caused by the COVID-19 pandemic.<\/p>\n

Interestingly, the initial focus of the trial in Zambia was not free distribution; instead it set out to increase distribution through the private sector<\/a>. While this approach was effective, it was the subsequent switch to the institutionalisation of free distribution that has ensured considerable and sustainable increases in coverage<\/a>. This approach excelled due to government engagement with the local manufacturer to ensure continued procurement of large quantities of co-packaged ORSZ. The free, government-branded product is only available at public health facilities on presentation with a sick child. In contrast, the same co-packaged ORSZ product, branded for retail sale, is available over the counter for pre-emptive or emergency purchase from retail outlets nationally. The two product lines successfully co-exist; the consistent but relatively low volume retail sales are considered important by the manufacturer to keep production lines running continuously and provide caregivers choice.<\/p>\n

We have a moral and ethical imperative to prevent child mortality. However, there are also economic considerations. The death of a young child is a human tragedy, but it is an economic one too. With this in mind, and given the link between ORSZ coverage and reduced mortality, is it time for us all to focus more on supporting \u2018local ecosystems\u2019 \u2013 governments, local manufacturers and other local actors \u2013 to make the case and then support local efforts to sustainably \u2018institutionalise free\u2019?<\/p>\n

About the authors:<\/strong> Simon Berry and Jane Berry are the co-founders of ColaLife a UK-based charity that worked on the ground with Zambian partners to catalyse a sustainable system change for increased ORSZ coverage. Simon went on to instigate and then lead a global team effort to get co-packaged ORS and Zinc listed on the WHO Model Essential Medicines List and to co-found the ORS Zinc Co-pack Alliance (ORSZCA)<\/a>. Simon was awarded an OBE for services to global health in 2023.<\/p>\n

Rohit Ramchandani is a Doctor of Public Health and Associate Faculty<\/a> at the Johns Hopkins Bloomberg School of Public Health. He was ColaLife\u2019s Public Health Adviser and Principal Investigator of the implementation research in Zambia, also playing a key role in successfully getting co-packaged ORS and Zinc added to the WHO Model List of Essential Medicines.<\/p>\n

Competing interest: <\/strong>All authors are known for their interest in increasing ORS and Zinc coverage for the treatment of diarrhoea in children. In all cases this interest is non-commercial.<\/p>\n

Handling Editor:<\/strong> Neha Faruqui<\/p>\n","protected":false},"excerpt":{"rendered":"

  As we commemorate the twentieth anniversary of the 2004 global recommendation of oral rehydration salts and zinc sulphate (ORSZ) as the standard treatment for diarrhoea, sub-Saharan Africa continues to face persistently low coverage rates (19%). Diarrhoea remains a leading cause of child mortality, responsible for approximately 9% of all deaths among children under age […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":402,"featured_media":39969,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[387,1],"tags":[115],"class_list":["post-40015","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-children-and-youth","category-uncategorized","tag-ors"],"yoast_head":"\nExpanding ORS\/zinc coverage for childhood diarrhoea: is institutionalising free distribution the answer? - BMJ Global Health blog<\/title>\n<meta name=\"description\" content=\"This blog reflects on a systems change approach which may institutionalise the free distribution of ORS and Zinc\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/bmjgh\/2024\/11\/25\/expanding-ors-zinc-coverage-for-childhood-diarrhoea-is-institutionalising-free-distribution-the-answer\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Expanding ORS\/zinc coverage for childhood diarrhoea: is institutionalising free distribution the answer? 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