"Phase 2", our first ORS & zinc scale-up round

Hello! We have just wrapped up a very busy period preparing for “Phase 2”, our first scale-up of ORSZ distribution, aiming to reach 20,000 children under-5 in two new areas in Kano, Nigeria. Community Health Workers concluded their distribution 2 weeks ago and we now await a set of follow-up surveys to ascertain how treatment of children’s diarrhoea changes.

Phase 2

What were our goals?

• Go bigger, 3x scale-up from pilot, targeting distribution to 20,000 children under-5

• Increase the robustness of the evaluation with a quasi-experimental design. Though this is not an RCT (due to a lack of true randomisation), we also survey nearby "no distribution" settlements for comparison.

• Partner much more closely with existing primary healthcare structures (training and supervision of Community Health Workers and other staff) to increase scalability and reinforce the healthcare system.

• Continued close collaboration with implementation partner, iDevPro Africa.

• Expand to new local government areas (Dambatta and Wudil, Kano) in more rural settings.

How did it go?

We await the first follow-up survey (1 month after distribution) and have some analysis to do on baseline and operational monitoring data, but early signs are positive! Reports from the field teams indicate that distribution went ahead as planned, and though survey teams suffered transport disruption from heavy rains, they all returned safely having reached enough householders. We expect to have initial results later in June.

What next?

We have started planning for “Phase 3”, later in 2024. This continue scale-up with tests of several variants of the intervention to hone in on the most cost-effective approach. Here is some of our current thinking:

• Consolidate government-led structure with our “Train the Trainer” model with existing primary healthcare staff.

• Build sophistication in our use of GIS (Geographic Information Systems) to plan, distribute and evaluate with greater rigour.

• Explore a platform-based strategy to ‘layer on’ different cost-effective interventions on top of ORS and zinc. More information on this will follow in the near future!

• Explore different distribution modalities such as facility- or chemist-based distribution and compare the cost-effectiveness to our base model.

Pilot results from Kano, Nigeria

Hello from Clear Solutions co-founders Charlie and Martyn!

We’re excited to share with you the results of our ORS and Zinc community distribution pilot in Kano, Nigeria. We give a quick overview below, with many more details in the full report. There are important caveats, but our takeaway is that the intervention led to a meaningful increase in ORSZ usage and we should take it forward with further operational improvements.

Pilot recap

Between Dec’23 and Feb’24, we ran a pilot distribution of oral rehydration solution and zinc (ORSZ), low-cost and highly effective treatments for diarrhoea. We completed this in Kano, Nigeria, with our implementation partner iDevPro Africa.

Community Health Workers (CHWs) distributed ORSZ ‘co-packs’ to ~6900 children under-5 across 20 communities. During the visits, caregivers (mostly mothers) were advised on using the ORSZ to treat the children’s diarrhoea and were provided with pictorial+written instruction sheets. Survey staff recorded diarrhoea treatment behaviours pre- and post-intervention to enable estimation of change in ORSZ treatment rates.

Pilot Outcomes

We observed an increase in the usage rates of 42.0 - 52.8 pp in ORS use and 61.5 - 83.0 pp for ORSZ across 4 wards (sub-geographies). This was a larger-than-expected change which is promising but needs to be interpreted carefully given several limitations in our pilots (see below). We also measured the ‘diversion’ of our ORS sachets to older age groups > 5 years old to understand the proportion of our products that would be available for our intended users. Across the wards, the diversion rate ranged from 13-21%. This doesn’t qualitatively change our view of the potential for the intervention, but more needs to be done to understand the accuracy and impact of this figure.

Though these results are very promising, we treat the apparent effect size with caution. For example, social desirability bias may inflate self-reported ORSZ usage rates, the pilot had partial (6.5% of households) overlap with a nutrition program that provided ORS, and our data collection does not fulfil all of the assumptions of the statistical methods used. We strive to improve upon all of these limitations in our next operational round. For more details on our limitations, please refer to our full report.

Read more in the full report

What's Next?

We plan to balance scale-up and building upon the learnings to date with operational variants aimed at improving the core intervention. Near-term, we aim for the next major round of operations May-June’24, with up to 3x pilot scale (~16,000-20,000 children under-5) and a subset of the more significant operational variants we elaborate in the report “Next Steps”.

Announcing our ORS & Zinc distribution pilot

Hello, thank you for reading! 

Clear Solutions is 4 months old and we have lots to share in our inaugural blog post!

ORS & Zinc Distribution Pilot

Our Kano, Nigeria, pilot in Dec’23 had local Community Health Workers (CHWs) distributing free co-packaged Oral Rehydration Solution and Zinc (ORSZ) door-to-door with detailed guidance to parents on using it to treat diarrhoea in children under-5. 

Diarrhoea is the 2nd largest cause of death in under-5s; ORSZ is cheap (<$1 per co-pack) and highly effective at reducing deaths. During the pilot, over 7000 co-packages of ORZ were provided to approximately 4000 households in Kano.

Robust impact evaluation is core to our approach. We survey householders’ diarrhoea management norms beforehand (“baseline”), verify that ORSZ and usage guidance were correctly provided (“spot-checks”), then return >4 weeks later to determine post-intervention ORSZ usage patterns (“follow-up”). Follow-up surveys for the pilot are starting this week.

Our backstory

We are thrilled to have been able to realise the pilot so quickly - it’s been an intense few months! Here is a brief look back.

Listening to the veterans

Millions of diarrheal deaths have been prevented in countries where ORSZ usage has been successfully increased. We truly appreciate the experience shared with us by ORSZ veterans from R4D, CHAI, USAID, ColaLife, ARFH-NG, SFH and others. 

 The relatively-novel ”free pre-emptive community-level distribution” intervention that we are evaluating in Nigeria, based on the Wagner 2019 Uganda RCT, may be a crucial catalyst where ORSZ usage remains low despite previous efforts. Our ability to scale and sustain an approach, perhaps institutionalising free community-level provision through government, will be key in the longer-term.

Building partnerships 

We narrowed our geographic focus to a final 3 countries (Nigeria, Ethiopia, Madagascar) with factors including diarrheal under-5 mortality, current ORS/zinc usage, and tractability. In each country, we identified potential on-the-ground implementation partners to execute our pilot and began governmental outreach in the first two. In Nigeria, we found several highly-capable local NGOs in different states, and began planning for up to 3 parallel “mini pilots”.

On the ground in Nigeria

Visiting communities, partners and government in Nigeria in November was fundamental to us truly understanding the context and growing partnerships with local NGOs and Government Primary Health Care agencies. 

We met potential partners in Federal Capital Territory, Gombe, and Kano, with online workshops for Enugu state. Focus groups with caregivers and community health workers rooted us in the day-to-day reality of the people we seek to support. 

The visits culminated in an opportunity to go bigger & faster than originally planned, with Kano State Ministry of Health approval and partner iDevPro-Africa having a window to start a larger pilot with pre-post ORSZ usage evaluation round, if we could get all the details in order in 2 weeks! 

Pilot execution

Clear Solutions co-founder Charlie spent most waking hours with iDevPro in Kano in the run-up to and first week of the pilot. Though the intervention is conceptually simple, every implementation detail needed to be determined: target communities; health worker staffing & supervision; survey staff, questions & tooling; procurement & co-packaging; detailed roles and staff training.

 A huge collaborative effort saw Pilot stage 1 (¼ of the volume) begin early-December, with a 2-week offset for us to incorporate learnings into the larger stage 2 from mid-December.  A brief pause, some initial analysis to validate the data collected so far, and it’s on to the Follow-Ups now until mid-February!

A huge thank you to everyone who has supported us to date, with partnership, funding, advice, and encouragement!