Layering ORS and Zinc provision onto existing health delivery infrastructure

In our first 15 months operating in Nigeria, the team at Clear Solutions are proud to have distributed ORS and zinc (ORSZ) to caregivers of an estimated 65,000 children under-5 in Kano state. We iterated in 3 major phases to build scalability and robust monitoring & evaluation methods, collaborating with the state primary healthcare system to engage community health workers (CHWs). The CHWs distribute ORSZ door-to-door in communities, giving caregivers a co-packaged box including ORS and zinc (“co-pack”) for each child under-5, to use as and when the child suffers from diarrhoea.

As we wrapped-up Phase 3 ORSZ distributions in February 2025, we set ourselves the challenge to further evolve the model to be as cost-effective, scalable, and sustainable as possible.

Through that lens, we think that layering ORSZ provision onto carefully selected existing health delivery infrastructure can be a major advance. “Infrastructure” in this context can vary from door-to-door health services that reach the same target populations, eg. seasonal malaria chemoprevention for under-5s; or fixed points where caregivers of under-5s already interact with health services, eg. immunisation sessions or local medicine vendors.

“Layering” isn’t a panacea for intervention delivery: there are trade-offs with complexity, potentially also with reach; and not all interventions serve the same populations at the same time of need. But ORS and zinc are well-suited to layering (light, durable in dry environments, with flexible timeframe for “preemptive” distribution), and we see several distribution models that complement our ORSZ program well and may unlock significant extra cost-effectiveness and scale.

This month, we will start provision of ORSZ co-packs to caregivers of infants at routine immunisation clinics and community outreach sessions in Kogi, Nigeria, in partnership with Notify Health and the Kogi State Primary Healthcare Development Agency. Layering upon the immunisation delivery infrastructure reaches infants under 2 years old, who are at especially high risk of death from diarrhoea. Our pre-post evaluation of this approach will give us insights into ORSZ treatment rate increase amongst other metrics to help evaluate the effectiveness of this type of layering approach.

We are also planning to layer ORSZ provision onto a door-to-door distribution to under-5s in Chad, starting July this year. We’ll be able to write more soon, but suffice to say, this is a crucial opportunity to serve children who suffer terribly high rates of mortality from diarrhoea in a cost-effective and scalable manner.

Thank you as ever for your interest, and we look forward to sharing more about these opportunities soon!

Building the Distribution Team in Gwarabjawa

From 2023 to date, Clear Solutions, in partnership with Kano-based iDevPro Africa and the Ministry of Health, has distributed Oral Rehydration Solution and Zinc (ORSZ) copacks to under-5s in vulnerable households and communities across Kano State in Nigeria. Providing free ORSZ copacks to caregivers ensures they have the treatment at hand and are able to use it when a child has an episode of diarrhoea. This is being done in contexts where it is common that:

1. Primary healthcare centres are poorly equipped and under-staffed

2. Settlements are not easily accessible because the roads leading to them are poorly maintained or non-existent.

In addition, the only form of address in many of the settlements where we work is "After the vegetable market, count six houses on your left." or "From the mosque, head east until you reach a fork in the path. Take the right path and look for a house with a mango tree in front of its doorway." These make for a challenging distribution environment. There have been times where at the end of a distribution round, we felt we were left with more questions than answers.

Phase 3 distributions in Dambatta, Kano

Beyond our stated goal of reducing diarrhoeal deaths in young children by promoting access to, and usage of, oral rehydration solution and zinc, Clear Solutions has also been having a positive impact in other ways. In February, Clear Solutions aims to distribute 18,500 ORSZ Copacks in Gwarabjawa, the largest Ward (Political Unit) in Dambatta Local Government in Kano State. Our door-to-door distribution model relies on Frontline Workers who are often selected from the volunteer cadres of Community Health Workers (CHWs) in the Primary Healthcare system and work for a number of days in exchange for a stipend.

When we introduced the use of Android devices to perform distribution monitoring in Phase 3, we hoped to reduce the time it took to do data entry from paper forms. This required engaging digitally literate volunteers, which can be a challenge in rural areas. 

For the February distribution, facing an absence of locally-resident candidates from the volunteer CHW cadres, Clear Solutions worked with Primary Healthcare and Community Leaders in Gwarabjawa to identify and train 18 young women in digital data entry and ORSZ distribution within their communities. These women, who are often Secondary School Certificate Holders have shown a willingness to give back to the community.

Frontline Workers with their worksheets during training

Over a two-day period, a team from Clear Solution's implementation partner in Kano State, iDevPro, trained community volunteers to complete surveys on Android devices. The training utilised a hands-on approach that focused on teaching transferable skills: smartphone navigation, accurate data entry and basic troubleshooting in addition to soft skills such as interview techniques, cultural sensitivity, communication and data collection ethics.

Armed with new confidence and skills, the 18 Frontline Workers are currently on track to distribute 18,500 ORSZ copacks to eligible households across Gwarabjawa. Their familiarity with the locality, knowledge of routes and their status as community residents makes them suitable for carrying out distribution in areas that may be challenging to navigate for outsiders. Furthermore, it is our hope that these young women can also serve as role models in their communities and encourage others to pick up new skills.

This represents a new innovation in our approach where we leverage upon partnerships with the community to build the talent pool in areas where we work thus providing opportunities for hardworking young people and also boosting the economy in local communities. The Primary Healthcare system also benefits immensely as they can now take advantage of trained volunteers to conduct digital surveys in future. In Gwarabjawa, this approach has shown remarkable success. We hope to test it further in more communities as we refine our model but initial results indicate this approach is both replicable and sustainable.

Frontline Workers practicing with smartphone distribution records during training

Digitising distribution monitoring for rigour at scale

Clear Solutions and partners have now completed 3 months of distributions in our ORS+zinc program “Phase 3” in Dambatta LGA in Kano state, Nigeria.

We made digitisation of distribution tracking - a key requirement for rigour at scale - our primary focus for this phase. By equipping the community health workers who perform our ORSZ distributions with smartphones, recording their GPS tracks and simple survey inputs, we can clearly understand the coverage achieved and monitor day-to-day progress.

Let’s take a closer look at the mapping and digitisation methods.

Distribution Planning

Our Phase 3 approach has been to distribute to children under-5 across whole geographic wards. Depending on ward size, this typically means 5,000-15,000 under-5s. We refer to population data from the Local Government Primary Healthcare teams, from the ward itself, and also estimates from WorldPop (which fuses satellite imagery with models based on census data).

For detailed mapping of the distribution areas, we use Geographic Information Systems (GIS) data from sources including GeoPode. The image below shows part of Dambatta, the Local Government Area (LGA) in which we have worked in Phase 3

Dambatta built-up areas (orange), small settlement areas (purple), and hamlets (pink)

Planning and supervision of distributions involves close collaboration with the local primary healthcare teams, and they assign specific communities to individual distributors. We define target areas in our digital maps to correspond with the intended distribution coverage, fusing settlement boundary data with expected under-5 population from WorldPop.

The distribution target area maps are split into grid squares in which it is expected that at least one under-5 is resident. Distribution teams do not refer directly to these GIS maps - they use their local knowledge and on-the-ground observations - but we can track their progress against the expected areas of distribution to estimate our effective coverage.

Tracking the distribution and estimating coverage

As the Community Health Worker teams proceed on their distributions, they carry a smartphone to record GPS positions along their paths.

We used low cost Android phones with Geospatial Tracking System (GTS), a tool originally developed for supporting polio immunisation campaigns by Novel-T Sàrl.

GTS consists of a smartphone app with a backend (cloud) data store and dashboard web app. The mobile app runs as a GPS location tracker to record ORSZ distributors’ paths, and as a survey tool (integrating Open Data Kit, ODK Collect app) for capturing operational monitoring data.

The individual distribution paths are aggregated by GTS into a map of the areas that have been reached within the distribution round, and those in which we expect there to be under-5s who have not yet been reached. Each handover of ORSZ is also recorded to monitor for stock levels and detect potential losses.

A coverage map builds up during the distribution, pictured above with target areas reached in green, and not yet reached in red. The geo coverage is a pure % of target areas reached, with the % of under-5s (according to GIS data, “GIS u5s” in the image) accounting for more densely populated areas. This gives us a robust indication of the reach of distributions, and enables us to iterate upon the planning and operational methods to further increase coverage.

Incorporating digital monitoring going forward

As we reflect on Phase 3, this digitisation of distribution monitoring has provided crucial practical insights into the operation, enabling continuous iteration and improvement. We expect to incorporate these methods as a standard component of our distribution campaigns going forward.