Collaborating with Helen Keller Intl to integrate ORSZ distribution with vitamin A supplementation during MNCHW in Nigeria

At Clear Solutions, we are exploring the potential of layering oral rehydration solution and zinc (ORSZ) distribution onto existing delivery platforms to expand access efficiently and at scale. This journey began last year through our partnership with Malaria Consortium in Chad, where we piloted the integration of ORSZ distribution into Seasonal Malaria Chemoprevention. The program outcome reinforced the promise of layering as a practical strategy for reaching children with life-saving treatments (results to be published soon).

We are now excited to announce a new partnership with Helen Keller Intl to pilot the integration of ORSZ distribution into vitamin A supplementation during Maternal, Newborn and Child Health Week (MNCHW) in Taraba state, Nigeria. Together, we aim to test whether this established child health platform can be used to get effective diarrhoea treatment into households before a child becomes sick, while preserving the quality and reach of existing services.

Why this matters

Diarrhoeal disease remains a major cause of illness and death among children under 5 in Nigeria, with 15% of children in Taraba experiencing diarrhoea annually. Despite ORS and zinc being simple, inexpensive, and highly effective treatments, only 25.5% of children with diarrhoea receive them.

Why MNCHW is a promising platform

MNCHW is a government-led campaign platform that already reaches large numbers of children with essential services, including vitamin A supplementation (reaching more than 80% of children), deworming and routine immunisation, through health facilities and outreach sites. It benefits from structured microplanning, standardised training and daily supervision. Since caregivers are already bringing children to these service points, MNCHW offers a strong opportunity to layer in ORSZ distribution without creating a separate delivery system.

Health workers registering Children at the facility

What the pilot will do

The pilot will be implemented during MNCHW in Bali LGA, Taraba State. Caregivers of children aged 0-59 months attending MNCHW services will be eligible to receive 2 ORSZ co-packs. Children aged 6-59 months will continue to receive vitamin A supplementation under the standard protocol.

Caregiver education is a central part of the model. At service delivery points, caregivers will receive a short group health talk. This will cover risks of diarrhoeal disease, the efficacy of ORSZ treatment, proper ORS preparation, administering the full course of zinc, and identifying danger signs that require further care. This will be reinforced with a brief check at handover and an illustrated take-home instruction leaflet.

Our monitoring and evaluation approach

The pilot’s M&E strategy is designed to be rigorous while also being practical and embedded in existing systems.

The main evaluation will be integrated into Helen Keller’s standard post-event coverage survey (PECS), which is conducted after the campaign by a third-party survey firm. The survey will mainly assess whether caregivers report receiving ORSZ and whether children received both vitamin A and ORSZ as intended.

Alongside this, monitoring will be adapted to include ORSZ indicators in tally sheets and summary forms. This will allow the team to track administrative coverage, review day-to-day implementation, monitor stock flow and stock-outs, and identify areas that may require corrective action or mop-up. Importantly, the pilot will also monitor vitamin A coverage in the pilot area to ensure that the addition of ORSZ does not compromise the reach or quality of existing MNCHW services.

A child receiving VAS

What we hope to learn

This pilot is designed not only to deliver ORSZ, but to generate practical evidence on whether and how this approach could be expanded, especially since fixed point delivery is relatively new to Clear Solutions. We want to understand whether ORSZ can be layered onto MNCHW in a way that is operationally feasible, scalable, and cost-efficient, while maintaining the strength of existing vitamin A services.

Pilot: ORSZ vouchers with local medicine vendors

Clear Solutions reduces child mortality from diarrhoea by improving access to, and usage of, highly effective treatments, ORS and zinc (ORSZ). We have increased focus on ‘layering’ free ORSZ provision onto existing health infrastructure (as opposed to dedicated door-to-door distributions, see layering blog post), and see local medicine vendors as key potential partners. In northern Nigeria, patent and proprietary medicine vendors (PPMVs, or ‘kemis’) are present in a large proportion of communities, even in more rural areas, and are often a caregiver’s first point of call if seeking help for a sick child.  

Aiming both to reach a large proportion of caregivers in communities, and to improve upon the costs involved in regular dedicated door-to-door campaigns (as may be required to sustain treatment coverage over time), we decided to pilot a voucher system with PPMVs. The model uses vouchers issued to each primary caregiver of children under-5 within a community, with the vouchers reusable for periodic claiming of free ORSZ (and/or other commodities) over a period of a year+. Each voucher has a QR code that is scanned by the vendor to record redemption of the voucher and prevent repeat claims within a defined time period.

We are building this distribution model guided by evidence from voucher program RCTs, including for chlorine water treatments in Dupas et al, 2017; & Dupas et al, 2023, which showed strong results in Kenya and Malawi respectively. Indeed, we see potential for our voucher implementation to work well for point of use chlorine water treatments such as Water Guard Plus, which may be a strong complement to ORSZ. But first, we are focused on refining and evaluating the model for ORSZ.

Pilot structure

For the purposes of a short-term pilot, we issued 2 identical single-use vouchers per caregiver instead of the more physically robust reusable format mentioned above. This was to manage caregiver expectations around the duration of the pilot (2 vouchers = 2 months), in anticipation that learnings from the pilot would lead to changes in the vouchers themselves in future iterations. It also meant that we could test the scanning technology handling of periodic scans of the same voucher code (like a single re-usable voucher) , while also - for the pilot only - having the PPMVs collect the paper vouchers as a backup to the digital tracking system.

The pilot was implemented by 4 PPMVs serving communities in Kabo local government area (LGA), Kano state, Nigeria, from November 2025 to January 2026. We worked in partnership with iDevPro Africa, Kano State Ministry of Health, and the PPMV trade association NAPPMED.

To evaluate the impact of the intervention, a survey team performed household surveys of caregivers before and after the vouchers implementation period. The primary outcome measure is the proportion of under-5s’ diarrhoea cases treated with ORS and zinc, with contextual information and feedback on the pilot implementation also collected.

Distributing & registering the vouchers

In each of the communities served by the pilot PPMVs, 1-2 local women (“Frontline Workers”, FLWs) who had been recommended for the role by the Community Leader, went door-to-door through the community to provide vouchers to caregivers with children under-5, aiming to reach all eligible households. 

Each caregiver was provided with a ‘voucher strip’ like the one below, perforated for ease of use. The Hausa text includes the brand “Garkuwar Iyali” (Family Shield), which we coined to represent the voucher program. The instructions inform caregivers that the vouchers must be used at least 4 weeks apart, the enforcement of which tested the system for spacing repeat claims over time as planned for reusable vouchers.

In addition to the vouchers, the FLWs gave caregivers a leaflet explaining ORSZ usage and triggers to seek further care, in Hausa language with pictograms for those who cannot read, plus a verbal explanation of the leaflet and the voucher system. FLWs registered each voucher strip by scanning the QR code with an Android phone and recording the number of under-5s looked-after by that caregiver.

Redeeming vouchers

PPMVs were trained on using an Android app to scan the QR codes on vouchers. The app, a custom configuration of CodeREADR, loaded the number of under-5s associated with each voucher code and uploaded voucher scans for monitoring when mobile connectivity was available. PPMVs were paid a participation incentive that included an allowance for mobile data costs and were asked to sync the app daily.

When a registered voucher was scanned, the app told the PPMV how many ORSZ co-packs to provide to the caregiver, based on the registration information that includes the number of children under-5 that the caregiver looks after. Unregistered or invalid voucher codes were rejected. The app also checked the date of any previous successful scan of the voucher code, and informed the PPMV how many days until the voucher could be used. (Recall that though we gave 2 single-use vouchers for pilot purposes, these had the same voucher code as we were also testing the capability to manage periodic repeat scans of the same re-usable voucher.)

In-person supervisory checks of the PPMVs work on the vouchers implementation (ie. visiting to check they were using the app correctly, managing stock appropriately, etc) were performed by the local primary healthcare focal person and Clear Solutions directly. This same person also provided additional cartons of ORSZ to the PPMVs when needed, from bulk stock provided by Clear Solutions.

Monitoring & Evaluation

During the pilot, we monitored the stream of voucher scans uploaded by the PPMVs via CodeREADR. A high proportion of the distributed voucher strips had a first ORSZ claim within a week of the service going live. This is expected: we consider the voucher model to be primarily “pre-emptive” provision of ORSZ (ie. for caregivers to keep at home until needed). However, we also expect that a certain proportion of caregivers would use the voucher ‘reactively’ by redeeming the voucher when a child has diarrhoea.

Operational metrics:

• Voucher sets registered with caregivers: 1,898 sets of 2 vouchers

• Under-5s at registered households: 3,450

• Caregivers who successfully redeemed 1+ voucher: 1,601 (84% uptake)

• Total ORSZ co-packs provided for under-5s: 4,207

The second voucher in each strip could be used 4+ weeks after the first. We decided not to issue any sort of reminder to caregivers (eg. no town crier or SMS) to observe the ‘unprompted’ return rate. Within the short 2-month pilot, approximately ⅓ of caregivers returned to use a second voucher. The ORSZ provision, 1 co-pack per under-5, was quite ‘generous’, in that the expected proportion of children suffering from diarrhoea each month is approximately 20%. Therefore many copacks will not have been used within the first 4 weeks (ie. still retained until needed), and in a longer-running program, this 4 week spacing would likely be increased to 2 or 3 months.

There were also many scans in the first few days where the voucher registration was not in CodeREADR. This is an area for improvement, which we understand to be a combination of the delay between frontline workers (FLWs) registering the voucher, the registration being uploaded by the FLW, then the registration being downloaded by the PPMV; and also imperfect registration implementation by the FLWs.

Analysis of the household survey data is ongoing, but provisionally, the impact on under-5 diarrhoea treatments with ORS and zinc seems very high, similar to the level we have seen previously in Kano for door-to-door campaigns.

* direct question ("Did you use ORS and/or zinc?")

It is premature to draw firm conclusions from ongoing analysis work, but we take this as a preliminary signal in favour of investing further in the Vouchers program, iterating upon its implementation, and exploring its long-term potential. We'll share more as we progress in the analysis and reflections.

We’d like to reiterate our thanks to our partners iDevPro Africa, Kano Ministry of Health, NAPPMED, and the individual PPMVs, FLWs and supervisor from Kabo LGA, Kano.

2 Years Strong: Clear Solutions Celebrates Impact, Innovation, and the Future of Lifesaving Layering

This October, we celebrated Clear Solutions’ second anniversary, marking two years since our founding in 2023. It has been a period defined by rapid iteration, ambitious scale-up, and a crucial evolution in how we deliver life-saving treatments to children most in need. We are profoundly grateful for the journey so far and thrilled by the opportunities that lie ahead.

In just two years, we have achieved significant reach. We are proud to announce that, to date, we have provided oral rehydration solution and zinc (ORSZ) co-packs to caregivers of an estimated 95,000 children under-5!

In our intervention regions in Nigeria and Chad, rates of child mortality from diarrhoea are tragically high, hundreds-of-times greater than in high-income countries. Driving the life-saving use of oral rehydration solutions and zinc (ORSZ), by improving access and knowledge, is crucial to giving children the chance to live their lives.

Learning from Dedicated Distributions: Pilot through Phase 3

Our first 16 months of programming focused intensely on dedicated, door-to-door distributions of ORSZ, primarily in Kano state, Nigeria, in partnership with locally-led organisation iDevPro Africa. This approach, heavily informed by a randomised controlled trial model from Uganda (Wagner et al, 2019), allowed us to rapidly refine our implementation and monitoring strategies.

Pilot (December 2023 – February 2024) The pilot phase in Kano reached approximately 6,900 children under-5. Surveys conducted post-distribution indicated a strong increase in the proportion of under-5 diarrhoea cases being treated with ORSZ. In the 4-week after distribution, surveys indicated a 42+ percentage points (pp) increase in diarrhoea cases treated with ORS and 61+ pp increase in combined ORS and zinc treatments compared to baseline. While we view these initial results with caution due to the simple pre-post evaluation methodology, they provided a solid directional signal in favour of iteration and scale-up. Read our pilot report here.

Phase 2: Scale-up and Closer Government Integration (Q2-3 2024) Phase 2 targeted reaching 20,000 children under-5, a nearly 3x scale-up from the pilot. Our focus shifted to testing operational scalability and enhancing evaluation rigour through a quasi-experimental methodology. A key milestone in this phase was the shift to a government supervision model, with leadership from the State Primary Healthcare system in training and supervising the community health worker distribution team. 

Phase 3: Digitisation and Precision Monitoring (Q4 2024 – Q1 2025) Phase 3 was critical for establishing the robust monitoring required for large-scale operations and reached an estimated 39000 children under-5. We fully embraced digitisation of distribution tracking, equipping CHWs with smartphones running GPS tracking tools. Given that communities often lack reliable household addressing systems, GPS recording provided crucial visibility into coverage, enabled highly effective supervision, and ensured accountability, which we consider a highly successful asset we take forward. Read more here.

Phase 4: The Layering Strategy and Geographic Expansion

As we concluded Phase 3, we reflected that the "last mile" effort in reaching every household with a single commodity was still a significant portion of the overall program cost, and was likely to remain that way even at large scale. To be as cost-effective, scalable, and sustainable as possible, we increased our focus on "layering" ORSZ provision onto carefully selected existing health delivery infrastructure, commencing in Q2 2025.

Phase 4 spans 3 different layering models:

1. Malaria Consortium SMC Layering in Chad: We expanded geographically to Chad in recognition of its extremely high diarrhoeal mortality rates and neglected status in ORSZ programming. We are partnering with Malaria Consortium to pilot integrated delivery of ORSZ co-packs alongside routine Seasonal Malaria Chemoprevention (SMC) door-to-door campaigns. This pilot, covering one health district to reach approximately 13,000 children under-5 is being rigorously evaluated in partnership with Dr Zachary Wagner of the University of Southern California to build a solid evidence base to inform future plans.

Read more about our Malaria Consortium partnership here and here.

2. Primary Healthcare Facilities in Nigeria: In Kogi state, we partnered with Notify Health to provide free ORSZ co-packs to caregivers of infants during routine immunisation clinics and community outreach sessions. In Kano, we are piloting the reactivation of ORS Corners at seven Primary Healthcare facilities in partnership with the Kano State Ministry of Health. These corners serve as key health education centres, providing free ORSZ and instruction to caregivers who seek facility-based care.

3. Community Medicine Vendors (PPMV Vouchers): Recognizing that many caregivers seek ORSZ treatment from local medicine vendors (“PPMVs”), we have implemented a voucher system to provide free ORSZ to caregivers of under-5s at these vendors in Kab LGA, Kano, with pilot distribution beginning November 2025.

Layering infrastructure reduces distribution costs and management load, offering a strong pathway to achieving impact at very large scale.

The Path Ahead: Phase 5 and Beyond

Our strategy moving forward is clear: to scale-up the best layering approaches. Planning for the subsequent phases of expansion in 2026 is underway, focused heavily on Phase 5 & 6.

Conditional on the ongoing evaluation results from Phase 4, Phase 5 will involve substantial scale-up, including (pending partner discussions) growing the Chad SMC collaboration considerably, scaling up the ORS Corners initiative in Nigeria, and expanding free ORSZ provision via the PPMV vendor voucher system. We aim to continue identifying and assessing further promising layering opportunities, maintaining our role as the agile innovator within the ORSZ ecosystem.

Acknowledgements

None of this progress would be possible without our trusted team, partners, and the dedicated individuals on the ground.

Our successes are fundamentally built upon the strength of our partnerships. We thank our Kano implementation partner, iDevPro Africa, who have been instrumental since the 2023 pilot. We are also deeply grateful to the State and Local Government Primary Healthcare systems in Nigeria for their collaboration, providing the integration necessary for scalability and sustainability. And for the collaboration on ORSZ layering onto SMC in Chad, we also warmly thank all the team at Malaria Consortium.

Crucially, we must acknowledge the sheer hard work of the Community Health Workers (CHWs) from the VCM and CHIPS Primary Healthcare programs, who have performed the door-to-door distributions. They, along with the data enumerators and survey staff who conducted rigorous monitoring and evaluation, are the frontline workers who put this program into action in challenging environments. They truly embody our mission to reach vulnerable households and ensure that no child dies a preventable death from diarrhoea.

We also recognise and thank our funding partners, including Effektiv Spenden, Founders Pledge, GiveWell, and Ultra Philanthropy who enable this important work to happen.

Thank you for following our journey! We look forward to sharing more progress as we continue to evolve and scale our life-saving programs in 2026 and beyond.