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.

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!