Phase 3 distribution & growing the team

It’s been a busy few months here at Clear Solutions and we have lots of news to share! 

First, co-founder Charlie and I are thrilled to welcome new team members, Umar, Sahar and Oli (see Team page), joining in London, UK and Kano, Nigeria. With their wealth of experience in public health, community initiatives, education, and government, their skills and perspectives will be key in advancing our mission.

I’d like to thank again everyone who applied for the roles: it was a pleasure to meet so many talented people driven by social impact!

Phase 2

Our last major distribution, “Phase 2”, in partnership with iDevPro Africa, reached an estimated 20,000 children under-5 in Wudil and Dambatta local government areas (LGAs) in Kano, Nigeria. We had survey teams visit communities before distribution, and monthly afterwards June to August '24, to observe our impact upon rates of ORS and zinc treatments of under-5 diarrhoea. Surveys extended to nearby communities outside of the distribution scope, to provide comparison for a quasi-experimental evaluation.

In Phase 2 we integrated as much as possible with the local primary healthcare system, with a supervisory structure run by the ward and LGA primary healthcare teams, and distribution by government community health workers (CHWs) of  the VCM and CHIPS cadre. We also trialled hybrid paper-digital “machine readable distribution tracker” forms for CHWs to record their distribution.

Our full analysis is in progress, and we will publish more soon, but here are some learnings that we take forward:

1. The increased operational scale, across 8 wards in 2 LGAs, went smoothly, with the teams taking in their stride the practical challenges like heavy rain and the more rural locations.

2. Leadership and supervision by the State Primary Healthcare Management Board and LGA Primary Healthcare teams was a key component, and we thank again them for their support. We see this integration with the health system as a foundation for scalability and sustainability going forward.

3. Preliminary analysis of the survey data suggests impact (increase in % of children under-5 diarrhoea cases treated with ORSZ) was comparable to our pilot: more on that coming soon!

4. The machine readable paper monitoring forms (scans processed by a machine learning system) was of mixed success: certainly more scalable than human data entry, and extraction of records into a digital structure worked well, but handwriting remains challenging even for modern systems to recognise reliably. This and other limitations are a focus in Phase 3.

Phase 3

The next iteration of the distribution program, “Phase 3”, starts this month, November 2024, in Dambatta LGA, Kano. Our focus is on establishing final missing pieces for growth to large scale: distributing to whole wards at once (to then combine to LGA-level coverage), and digitising monitoring of the distribution. (For context, our surveys have all been digital, but distribution involved paper trackers.)

To record distribution paths, and aggregate these to determine coverage across a population, we are partnering with Novel-T, former WHO engineers who have built tools to support the Global Polio Eradication Initiative. There are many operational similarities between door-to-door polio vaccinator teams and ORSZ distribution that lend themselves to a common digital toolkit.

The CHWs distributing ORSZ in Phase 3 are equipped with smartphones running Novel-T GTS tracker, giving detailed insights into geographic coverage. We will be using these insights to tune the operation to reliability and transparently reach whole populations.

Preparing settlement extents and target areas for distribution in Dambatta

We plan to post more on our experiences with GTS, and the GIS data that powers it, in a future blog. Watch this space.

Thank you!

A huge thank you again to everyone who has supported our mission against preventable child deaths from diarrhoea! To our health system partners, local partners iDevPro, our advisors, and the financial supporters who enable all of this: thank you, it really wouldn’t be happening without you!

"Phase 2", our first ORS & zinc scale-up round

Hello! We have just wrapped up a very busy period preparing for “Phase 2”, our first scale-up of ORSZ distribution, aiming to reach 20,000 children under-5 in two new areas in Kano, Nigeria. Community Health Workers concluded their distribution 2 weeks ago and we now await a set of follow-up surveys to ascertain how treatment of children’s diarrhoea changes.

Phase 2

What were our goals?

• Go bigger, 3x scale-up from pilot, targeting distribution to 20,000 children under-5

• Increase the robustness of the evaluation with a quasi-experimental design. Though this is not an RCT (due to a lack of true randomisation), we also survey nearby "no distribution" settlements for comparison.

• Partner much more closely with existing primary healthcare structures (training and supervision of Community Health Workers and other staff) to increase scalability and reinforce the healthcare system.

• Continued close collaboration with implementation partner, iDevPro Africa.

• Expand to new local government areas (Dambatta and Wudil, Kano) in more rural settings.

How did it go?

We await the first follow-up survey (1 month after distribution) and have some analysis to do on baseline and operational monitoring data, but early signs are positive! Reports from the field teams indicate that distribution went ahead as planned, and though survey teams suffered transport disruption from heavy rains, they all returned safely having reached enough householders. We expect to have initial results later in June.

What next?

We have started planning for “Phase 3”, later in 2024. This continue scale-up with tests of several variants of the intervention to hone in on the most cost-effective approach. Here is some of our current thinking:

• Consolidate government-led structure with our “Train the Trainer” model with existing primary healthcare staff.

• Build sophistication in our use of GIS (Geographic Information Systems) to plan, distribute and evaluate with greater rigour.

• Explore a platform-based strategy to ‘layer on’ different cost-effective interventions on top of ORS and zinc. More information on this will follow in the near future!

• Explore different distribution modalities such as facility- or chemist-based distribution and compare the cost-effectiveness to our base model.

Pilot results from Kano, Nigeria

Hello from Clear Solutions co-founders Charlie and Martyn!

We’re excited to share with you the results of our ORS and Zinc community distribution pilot in Kano, Nigeria. We give a quick overview below, with many more details in the full report. There are important caveats, but our takeaway is that the intervention led to a meaningful increase in ORSZ usage and we should take it forward with further operational improvements.

Pilot recap

Between Dec’23 and Feb’24, we ran a pilot distribution of oral rehydration solution and zinc (ORSZ), low-cost and highly effective treatments for diarrhoea. We completed this in Kano, Nigeria, with our implementation partner iDevPro Africa.

Community Health Workers (CHWs) distributed ORSZ ‘co-packs’ to ~6900 children under-5 across 20 communities. During the visits, caregivers (mostly mothers) were advised on using the ORSZ to treat the children’s diarrhoea and were provided with pictorial+written instruction sheets. Survey staff recorded diarrhoea treatment behaviours pre- and post-intervention to enable estimation of change in ORSZ treatment rates.

Pilot Outcomes

We observed an increase in the usage rates of 42.0 - 52.8 pp in ORS use and 61.5 - 83.0 pp for ORSZ across 4 wards (sub-geographies). This was a larger-than-expected change which is promising but needs to be interpreted carefully given several limitations in our pilots (see below). We also measured the ‘diversion’ of our ORS sachets to older age groups > 5 years old to understand the proportion of our products that would be available for our intended users. Across the wards, the diversion rate ranged from 13-21%. This doesn’t qualitatively change our view of the potential for the intervention, but more needs to be done to understand the accuracy and impact of this figure.

Though these results are very promising, we treat the apparent effect size with caution. For example, social desirability bias may inflate self-reported ORSZ usage rates, the pilot had partial (6.5% of households) overlap with a nutrition program that provided ORS, and our data collection does not fulfil all of the assumptions of the statistical methods used. We strive to improve upon all of these limitations in our next operational round. For more details on our limitations, please refer to our full report.

Read more in the full report

What's Next?

We plan to balance scale-up and building upon the learnings to date with operational variants aimed at improving the core intervention. Near-term, we aim for the next major round of operations May-June’24, with up to 3x pilot scale (~16,000-20,000 children under-5) and a subset of the more significant operational variants we elaborate in the report “Next Steps”.