Collaborating with Malaria Consortium on integrating ORSZ provision with seasonal malaria chemoprevention

Clear Solutions’ first 16 months of programming focussed on dedicated distributions of oral rehydration solution and zinc (ORSZ) in Kano state, Nigeria. The distributors were community health workers engaged through partnerships with the State and Local Government Primary Healthcare system, facilitated by locally-led NGO partner iDevPro Africa.

These dedicated distributions enabled rapid iteration and adoption of advanced approaches for planning, monitoring and evaluation (eg. leveraging geographic information systems (GIS) mapping data and distributors’ GPS tracks). We also came to appreciate that the “last mile” effort in reaching each household with a single commodity was likely to remain significant as a proportion of overall program cost (with commodity procurement the other major part), even - or especially - with increased scale. We have thus increased focus on “layering” ORSZ provision onto existing healthcare infrastructure to achieve distribution cost efficiencies and leverage networks already operating at scale.

We are therefore thrilled to announce a collaboration with Malaria Consortium, to pilot

integrated delivery of ORSZ through their seasonal malaria chemoprevention (SMC) platform in Chad in the coming months.

Chad suffers a very high rate of child mortality from diarrhoeal diseases, 560 per 100,000 children under-5 in 2021 (per Global Burden of Disease, the West Sub-Saharan Africa regional average being 197). ORS remains highly under-utilised, with MICS 2019 finding all regions of Chad had <30% of under-5 diarrhoea cases treated with ORS, and some regions <10%.

SMC protects young children aged 3-59 months from malaria by administering antimalaria drugs in regular intervals or cycles during the high-transmission rainy season. The pilot will test community distribution of co-packaged ORSZ alongside routine SMC delivery across a whole health district, expecting to reach ~13,000 children under 5 years old.

SMC operations in Nigeria, 2023. Credit: Malaria Consortium

ORSZ co-packs, one per child under 5, will be handed to caregivers during door-to-door SMC visits by trained community distributors, together with guidance on recognising diarrhoea symptoms, correct use of ORSZ, safe storage, and when to seek further care.

To maximise learning from the pilot, together we are taking a multi-pronged approach to monitoring and evaluation (M&E):

1. Formative learnings to guide implementation details, eg. informal community discussions. The implementing team will give feedback on the operational impact of co-distribution.

2. Malaria Consortium’s existing SMC distribution monitoring and coverage assessments will be extended to capture ORSZ data.

3. Independent quasi-experimental evaluation of the intervention impact on ORS treatment rates will be monitored in the months following the distribution.

Through these M&E activities, we plan to build a solid evidence base to inform decisions on scale-up of this model in future years.

We thank the Malaria Consortium team for their partnership and are excited for the opportunities for large scale impact that this pilot may unlock!

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