- Clear Solutions team
- Feb 5
- 5 min read
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.
