Vouchers for health: getting life-saving medicine within walking distance of caregivers in Kabo
Diarrhoea is still one of the leading killers of children under five in Nigeria, even though the treatment has been known to science for decades. A course of oral rehydration salts and zinc, known as ORSZ, costs very little and works. The difficulty is not the science. It is getting the sachet into a mother’s hand before the day her child needs it.
For a caregiver in rural Kano, that day usually begins with a calculation. The nearest health facility or medicine vendor may be several kilometres away, so reaching it means either a long walk or a transport fare. In the poorest households, that fare competes directly with the day’s food budget. A mother can find herself choosing between treating one sick child and feeding the others. Faced with that choice, many wait. Treatment that should begin within hours begins days later, or never begins at all.
Distance and cost are therefore the key constraints. Any solution that fails to remove them will not be effective, no matter how good the medicine is.
From carrying medicine to issuing vouchers
From December 2023 to February 2025, Clear Solutions tackled this through door-to-door distribution, with Frontline Workers walking their communities and handing out copacks directly. It reached people, but it tied every dose to a worker’s visit. A household had ORSZ on the day the worker called, then ran out before her next visit, and the cost of the model climbed with every community added.
Garkuwar Iyali (“Family Shield”) is our attempt at a different channel. The Frontline Worker no longer carries medicine; she carries a smartphone and a set of vouchers. She enrols the caregiver, issues a scannable voucher and explains how to use it, including a health talk on administering ORSZ and the signs that mean a child needs a health facility. The medicine itself waits at a fixed redemption point inside the community, and the caregiver collects it free of charge whenever it is needed.
The scheme rests on two things. The first is a scannable barcode, which makes every voucher unique, verifiable and countable. The second is a redemption point within walking distance, which is what actually removes the fare and the journey. Without the second, the first is merely a piece of paper.
Redemption points are places people already trust and already visit: the neighbourhood Patent and Proprietary Medicine Vendor (PPMV), a licensed retailer permitted to sell over-the-counter medicines, or the home of a community health worker vouched for by community leaders. Because the point is close and the medicine is free, both barriers fall away at once. Caregivers can also collect ORSZ before a child falls ill and keep it at home, which turns treatment from a journey into something already in the cupboard.
We check that “within walking distance” is true rather than assuming it. Mapping every registered household in Dugabau against the nine Service Providers we hold GPS coordinates for, we found 52% of residents living within 500 metres of a redemption point and 82% within a kilometre. The remainder are not scattered: they sit in three distinct pockets holding 3,699 people, among them 617 children under five, and that is where the next providers will go. These are straight-line distances, so real walking is longer and the gaps are, if anything, understated.
Four things make this work in practice.
1. It is built on evidence, not assumption
We tested the channel before scaling it. Between November 2025 and January 2026, we ran a proof-of-concept pilot across four communities of Dugabau Ward in Kabo Local Government Area (LGA). In it, 1,898 caregivers received a pair of single-use scannable paper vouchers redeemable at their neighbourhood PPMV. Vendors scanned each barcode on an Android app and dispensed 4,207 copacks across two redemption cycles of four weeks each.
Usage rates among pilot households rose sharply:
ORS use rose from 48.6% at baseline to 81.4% at endline.
Zinc use rose from 19.0% to 89.8%.
The redemption rate, meaning caregivers who used a voucher at least once in the two months, reached 84%. Uptake was strong enough to scale.
The pilot also showed us what to fix. Three changes went into the current phase:
Single-use paper vouchers were replaced with reusable ones, the size of a business card and printed on sturdier stock to resist wear, so a caregiver keeps one card across cycles rather than receiving a fresh slip each time.
Redemption points were extended beyond PPMVs to community and volunteer health workers, so communities with no local vendor still have a point within walking distance.
Recharge cycles now differ by ward: four weeks in Dugabau against two in Kanwa, so we can measure whether cycle length changes how much medicine caregivers actually claim.
That phase launched in May 2026 and extended coverage from four communities to every community in two wards, Dugabau and Kanwa. Both were selected for high diarrhoea prevalence alongside low ORSZ usage, which a fresh ward-wide baseline survey confirmed. These figures cover both wards in full, rather than the four pilot communities above:
Ward | Diarrhoea prevalence | ORS usage rate | Zinc usage rate |
Dugabau | 42.2% | 40.1% | 23.8% |
Kanwa | 28.7% | 44.2% | 10.5% |
The programme now covers 12,152 children under five. Based on redemption data so far, we expect to distribute roughly 60,000 copacks over six months, or about 5,000 per ward each month. Household surveys at midline and endline track ORS and zinc use, redemption levels, preparation and distance to the nearest redemption point.
Two of those are deliberately hard to fake. When a caregiver tells us she redeemed, we can check her answer against what the scanner recorded, and we ask her to demonstrate how she prepares ORS rather than describe it. A survey that only asks tends to hear the answer the caregiver thinks is wanted.
2. The people who deliver it belong to the community
Barcodes are easy to create. Trust is not, and trust decides whether a mother redeems a voucher. Frontline Workers are local women, selected and vouched for by community leaders. They go house to house to register caregivers and issue vouchers, and while doing so they teach: the correct volume of water for one ORS sachet, which is one litre, why zinc must be given for the full ten days rather than stopped as soon as symptoms ease, and the danger signs that mean a child needs to reach a health facility immediately.
Because these women speak fluent Hausa and live on the same streets as the households they register, questions get asked that would never be put to a stranger. That access matters as much as the medicine itself, since ORSZ only works when it is mixed correctly and the treatment course is completed.
3. Local government is an active partner, not an observer
The programme is implemented in active collaboration with the Kabo Local Government Public Health Department. Ward Focal Persons in Dugabau and Kanwa supervised the training of health workers, chose the redemption points in consultation with community leaders and oversaw voucher registration. They also monitor stock levels and arrange bulk pickups so that no redemption point runs dry.
This is deliberate. A parallel structure ends when the funding ends. Building the workflow into offices, staff and facilities that already exist, and into vendors who will still be trading next year, is what gives the model a chance of outlasting the pilot.
4. Real-time data drives both quick fixes and long-term design
Every scan is a data point. It records who redeemed, in which community, and how many copacks were claimed, and it syncs to a project database that the team reviews on a dashboard each day.
Averages hide problems, so we watch for specific patterns: vendor activity week on week, caregivers attempting to redeem before their cycle opens, communities where redemption is drifting downwards, a Service Provider who has not synced scan data for three days, a community that redeems only on a single day of the week.
Each flag triggers a proportionate response rather than an alarm: a spot-check visit from the Ward Focal Person, a conversation with community leaders about why uptake has fallen, or a revision to the training given to Service Providers and Frontline Workers.
One example. An alert fired when one provider logged around a hundred scans in a single day that all failed as unregistered. The codes were well formed rather than mistyped, which meant a batch of registrations had never reached the app and the families holding those cards were being turned away at the counter. Without the daily check it would have been invisible until someone complained.
Problems that would once have surfaced in an endline report now surface within the week. The same data also informs how the programme evolves: what to drop and what to trial next.
The impact so far
Since launching in May 2026, the programme has recorded:
6,593 caregivers registered with unique digital health vouchers
12,152 children under five covered across two wards
More than 5,300 caregivers have redeemed over 24,000 ORSZ copacks
What remains difficult
Every day teaches us something to improve in the next iteration.
Finding digitally literate residents willing to serve as Service Providers is hard in remote communities, where even a low-end Android phone is a luxury many cannot afford.
Connectivity is patchy across much of the area and absent in places, forcing Service Providers to travel simply to sync scan data or update the app.
Last-mile distribution is the most expensive leg. Copacks travel from the stores of our implementation partner, iDevPro Africa, to the ward’s apex primary healthcare facility, where Service Providers top up as stocks fall. Some communities sit far away or on the opposite side of a river, and the absence of tarred roads rules out trucks.
Getting the medicine into the house is not the same as the course being completed. In our baseline data, four in five caregivers who gave zinc stopped before the tenth day, most commonly on the third, once the child looked better. Free medicine within walking distance does not fix that on its own, which is why the health talk carries as much weight as the voucher.
What comes next
A midline survey is under way to test whether scannable vouchers paired with community redemption points really are a cost-effective, scalable way to deliver free ORSZ. Early modelling on this phase’s costs puts a six-month course of protection at under US$2 per child under five, though that figure moves with how often caregivers claim. Alongside diarrhoea prevalence and usage rates, we are tracking whether treatment is becoming more appropriate, measured by a fall in antibiotic use and by correct administration of ORSZ.
If the data holds, we plan to expand into further wards, aiming for full LGA coverage in 2027. We will also trial multiple commodities on a single voucher, adding chlorine (Waterguard+) for water purification in one ward. The question we are really testing is whether a barcode and a shop around the corner can carry more than one kind of medicine.
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