Expanding our partnership with Malaria Consortium to integrate Oral Rehydration Solution and Zinc into Seasonal Malaria Chemoprevention in Chad and Nigeria

Diarrhoea remains a major threat to young children's health, yet Oral Rehydration Solution and Zinc (ORSZ) - a simple, low-cost treatment - still isn't reaching the children who need it. At Clear Solutions, we're working to close that gap, including by exploring how ORSZ can be integrated into existing health programmes to reach more children efficiently and at scale.

Building on our successful 2025 pilot layering ORSZ onto Malaria Consortium's Seasonal Malaria Chemoprevention (SMC) platform in Chad, we're happy to announce that we're expanding our collaboration in 2026: scaling up across Chad and launching a new pilot in Nigeria's Kebbi and Sokoto states.

SMC is a community-based, highly effective malaria prevention programme that protects children aged 3-59 months during the high-transmission rainy season. Trained community distributors visit households door-to-door to provide antimalarial medicines and explain how they should be used - creating a natural opportunity to also hand caregivers ORSZ co-packs and counsel them on preparation, dosing and when to seek further care if a child develops diarrhoea. Although ORSZ will not be administered on the spot like SMC, providing it in advance at the household level could reduce delays in treatment initiation and improve its timely and appropriate use.

Our 2025 pilot in Chad showed that SMC is a promising platform for this approach, increasing ORS and zinc use by 74.1 and 68.9 percentage points respectively, while maintaining high SMC coverage (manuscript under review, 2026). In 2026, we are scaling up the model in Chad, while testing how it will perform in a different context in Nigeria.

By co-designing the programme, Malaria Consortium leads field delivery and evaluation, drawing on its established SMC infrastructure, while Clear Solutions leads ORSZ procurement and technical support for ORSZ adaptations in health worker and distributor training, caregiver education, as well as monitoring and evaluation.

This partnership is an important step toward building strong evidence that child-health platforms can deliver more than one life-saving intervention at a time, and toward showing whether high, equitable ORSZ coverage is achievable even in areas where access has historically been poor.

We thank the Malaria Consortium teams in Chad and Nigeria, the national malaria programmes, state and provincial health authorities, and all programme staff involved in designing and implementing these programmes.

Scaling up in Chad

Objectives To test whether the delivery model can sustain strong coverage and delivery quality when implemented across a much larger geographic area. Based on learnings from the 2025 campaign, an additional distribution day has been added to allow for sufficient time for caregiver education, and logistical support to carry around ORSZ co-packs has been put in place.

Where Mayo-Kebbi Est and Mayo-Kebbi Ouest provinces, covering all districts and health facilities

Size of the problem In Chad, diarrhoea causes an estimated 729 deaths per 100,000 children under five (GBD, 2023 (IHME)) . However, only 20% of cases are treated with ORS in Mayo-Kebbi Est and 17% in Mayo-Kebbi Ouest (DHS, Chad 2014).

Target population 463,871 children aged 0-59 months, 2 co-packs per child

Procurement ~1.1 million co-packs manufactured in Nigeria and transported by sea and truck to Chad

Distribution During 2 SMC cycles in August and October, with each child receiving 1 co-pack per cycle (i.e. 2 per child in total)

Surveys ORSZ questions integrated into End of Cycle and End of Round SMC surveys across 5 SMC implementing provinces by Malaria Consortium, with an increased sample size (End of Round survey) in Mayo-Kebbi Est and Mayo-Kebbi Ouest provinces

Piloting in Nigeria

SMC operations in Nigeria. Credit: Malaria Consortium

Objectives To optimise and learn from layering ORSZ onto SMC in the Nigerian context, including adapting training materials to Nigerian government standards, and to build a clearer picture of how delivery differs across countries and implementation contexts, informing future expansion and scaling decisions.

Where Argungu local government area (LGA) in Kebbi state and Silame LGA in Sokoto state

Size of the problem In 2023, diarrhoea caused an estimated 261 deaths per 100,000 live births in Kebbi and 315 in Sokoto among children under five1. Yet only 36.6% of children with diarrhoea in Kebbi and 48.4% in Sokoto received ORS (DHS Nigeria 2024).

Target population 123,768 children aged 0-59 months, 2 co-packs per child

Procurement ~273,000 co-packs manufactured in Nigeria and transported to Kebbi and Sokoto

Distribution During 2 SMC cycles in July and September, with each child receiving 1 co-pack per cycle (i.e. 2 per child in total)

Surveys Extensive ORSZ surveys in Argungu and Silame before distribution (baseline), after cycle 2 (1 month after first ORSZ distribution) and after cycle 4 (endline, 1 month after second ORSZ distribution), as well as integration of ORSZ questions into End of Cycle SMC surveys across all LGAs in Kebbi and Sokoto states.

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.