5 immediate recommendations to reduce child mortality in Zambia

This is a call to all to comment on 5 immediate recommendations to come out of the ColaLife Operational Trial in Zambia (COTZ). We are particularly interested in whether these are compatible with iCCM. Please add your comments below or email simon@colalife.org

 

5 immediate recommendations to reduce childhood mortality in Zambia

  • These actions can be run in parallel.
  • Action 4 is underway with Community Health Workers although the ‘immediate action’ messaging might need modification and there is a problem with the availability of ORS and Zinc.
  • Action 5 is routine but the messaging might need modification.

 

1 Embrace the existing urban and rural network of retail outlets* as a supply channel for co-packaged ORS and Zinc

  • In rural Zambia small, private retail shops are much closer to people’s homes than clinics
  • Stock-outs at shops are less frequent than stock-outs at health centres
  • You can get cooking oil in virtually every village in Zambia. You should be able to get co-packaged ORS and Zinc there too.
  • This needs NO new legislation as both ORS and Zinc are over the counter (OTC) medicines. Many grocery shops already sell other OTC items such as paracetamol and aspirin.
  • Co-packaged ORS/Zinc should have ORS sachets of a size suitable for the treatment of a single child in the home (200ml/4.2g). Four 200ml/4.2g sachets is sufficient
  • Ideally the packaging should act as a measuring device to help ensure the correct mixing of the ORS

* Non-pharmacies, non-health shops. The shops that sell cooking oil and sugar in communities.

 

2 Promote “start ORS and Zinc treatment immediately” as the first action to take/routine practice when a child gets diarrhoea

  • Note: additional actions may be needed if danger signs are present – see below)
  • Note: this recommendation is NOT synonymous with “go to the nearest health centre” as this may delay the start of treatment due to:
    • The distance to the health centre particularly in rural areas
    • Queues at the health centre
    • Stock-outs
    • Inconsistence of prescribing ORS and Zinc together

 

3 Make co-packaged ORS and Zinc available in all health centres

  • Currently less than 1% of children are being prescribed ORS and Zinc together due to:
    • Inconsistencies in prescribing practice
    • Low levels of supply of Zinc to health centres (10 treatments per 1,000 population per month)
    • Stock-outs of ORS and/or Zinc
  • Co-packaged ORS/Zinc should have ORS sachets of a size suitable for the treatment of a single child in the home (200ml/4.2g). Four 200ml/4.2g sachets is sufficient
  • Ideally the packaging should act as a measuring device to help ensure the correct mixing of the ORS

 

4 Para-skill retailers and Community Health Workers in diarrhoea and ORS and Zinc

  • Diarrhoea prevention
    • Hand washing
    • Breastfeeding
    • Safe water
  • Diarrhoea treatment
    • Start treatment with ORS and Zinc immediately
  • When to go to the clinic (the six danger signs)
    • Fever
    • Dehydration (skin pinch, sunken eyes and sunken fontanelle in infants)
    • Bloody diarrhoea
    • More than 3 watery stools per hour
    • Persistent vomiting/too weak to eat or drink
    • Lack of energy, lethargic or unconscious

 

5 Raise awareness amongst mothers and carers of how to prevent diarrhoea, of the first action to take when diarrhoea strikes (start ORS and Zinc treatment immediately) and when to go to the clinic (the six danger signs)

  • Diarrhoea prevention
    • Hand washing
    • Breastfeeding
    • Safe water & sanitation
  • What to do when diarrhoea strikes
    • Start treatment with ORS and Zinc immediately
    • Continue breastfeeding
  • When to go to the clinic (the six danger signs)
    • Fever
    • Dehydration (skin pinch, sunken eyes and sunken fontanelle in infants)
    • Bloody diarrhoea
    • More than 3 watery stools per hour
    • Persistent vomiting/too weak to eat or drink
    • Lack of energy, lethargic or unconscious

 

These recommendations are based on the findings for the ColaLife Operational Trial in Zambia (COTZ). The headline findings are here. Details of how to get access the details behind these headlines are here: colalife.org/openaccess.

 

Comments

  1. Via Email says:

    Hi Simon

    Food for thought on a Bank Holiday Monday!

    It seems to me there is a lot of overlap between messages 2, 4 and 5. Couldn’t these be re-packaged as a single message?, e.g.

    “Teach mothers, carers, retailers and health workers how to prevent diarrhoea and to start ORS and zinc treatment immediately diarrhoea strikes”

    After all, three messages are much more manageable than five!!

    All the best

    N

  2. Hello Simon

    Just to let you know I purchased a case of Kit Yamoyo ( 35/case) from Pharma Plus Ltd, Hitesh Patel in Lusaka.( 4 KW each) I divided the case up and gave kits to Lundazi District north of Chipata, Luoke West, (2.5 4×4 drive or 10 hr boat paddle) north of Kalabo on the Luanginga River, and Mongu. I explained fully how to properly use the kits.

    I just returned from a month in Zambia building my resource garden for farmers and a tree nursery in Mongu.
    I will be posting blogs on our web site as soon as I get organized. http://www.sendseedstoafrica.org.

    I realize you are trying to establish a set distribution system for the Kits but I also feel that NGO’s should have the option to buy the kits for the areas they work in to speed up the process of preventing deaths. I know it makes it difficult to charge the people who are buying the kits, if they are possibly getting them for free from NGO’s but it could also be a way of advertising them. NGO’s making it known that they are available.

    The whole point of your frustration all of these years has been that the people can buy Coke but do not have access to medicine. Does it really matter if deaths are being prevented, how that is done?

    You have said that you start out with a plan and it will inevitably change.

    After typing all of this I went back and read in your blog ( overview of Scale up) that you are including NGO’s through Pharmanova. That blog is a bit confusing. Anyway I am happy to hear that they will be available for NGO’s to purchase and look forward to hearing how you will get the word out to them.

    It is a great product. Thanks Joanne

    • Hello Joanne

      I really enjoyed reading your comment and it provides an excellent spring board for me to explain our approach which I understand might seem a bit “too private sector” for many who just want to get free medicines to poor people who desperately need them.

      We are delighted that you bought a box of 35 kits in Lusaka and to took them to the most eastern and western parts of Zambia as gifts – and took the time to explain to people how to use them. Most people reading this won’t realise the huge distances you travelled. The first thing to note here is that you didn’t have to contact ColaLife or any other ‘foreign body’ to get hold of the kits. You just went into a pharmaceutical wholesaler in Lusaka and bought them. Anyone can now do this – we haven’t had to set up a new organisation or new processes to do this – we’ve just used the organisations and systems that are already there. Furthermore, when the wholesalers want more stock they simply order from a Zambian pharmaceutical manufacturer – again with no reference to ColaLife.

      The second thing to note is that you are a special person! But you are only one person and you won’t do the trip you did again for a while so you are not a reliable distribution system by yourself! So although people are aware of Kit Yamoyo because of your actions, they cannot rely on you to supply them consistently in the future. They can’t rely solely on the public sector either. In our trial areas, before we started, <1% of children were getting the recommended treatment for diarrhoea (ORS and Zinc). And this is a treatment that has been recommended for 10 years at international level and adopted as policy by the Zambian Government 5 years ago. Within our trial areas this rose to 45% of children getting the right treatment within one year and this all came through the private sector - small community shops.

      What we have done is demonstrate that if you can develop a health product that people WANT (not just need), price it a level they can afford and make it profitable for manufacturers to make it, distributors to distribute it, wholesalers to stock it and retailers to sell it then it will get to even remote communities 'by itself'. Just like Coca-Cola does.

      Free medicine it not free in real terms. Assuming no corruption, it may be free at a public health centre, but a carer of a sick child will still have to get there and if this doesn't cost money, it will cost time and the well-being of the sick child. When you get there, the facility might be out of stock and you will be advised to travel to the nearest town to buy. While you are away from your community you'll probably have to buy food for yourself and your child. Contrast this with paying the equivalent of 5 eggs for treatment close to home.

      We would have no problem with an NGO buying kits and giving them away free as long as they commit to doing this reliably and FOREVER! Because by doing this they will destroy any chance of the private sector getting involved and the chance of this sector doing it reliably and forever.

      And finally, our approach contributes to a better livelihood for rural shopkeepers and their dependents. This extra money will circulate many times in the local community and much of it will be spent on better nutrition and health (especially if the shopkeeper is a woman).

      I hope that one of the people you gave the kit to was a shopkeeper or had a shopkeeper in the family (which is likely) and they seek a source of supply and bring to their village to sell. In Lundazi, they will find a wholesaler in Chipata within the next two weeks.

      Thanks again for your comment.

      Simon

      • Thanks Simon for your detailed explanation. I agree with all that you have said. In response to your last paragraph, yes the person in Luoke West, north of Kalabo is a shop keeper and also a local Councillor. I did have the discussion with Mwualuka and gave him the option of charging for the kits and selling them out of his shop and keeping the money himself as he has helped me immensely with my projects. He is a smart kind hearted man and I totally trust him. He told me that he was going to turn them over to the Luoke West Health Centre to be handed out by the resident nurse. I felt a little guilty as I understand and appreciate what you are doing and that mothers will spend the money to help their children and I don’t want to disrupt your goals.
        On the other hand I was pleased to find out that they do have a “trained” nurse who will be dispensing the kits. I have taken samples of medications ( my real job is working with GP’s) to him for three years now and he has always handed them into the nurse to share with the village.
        I gave Mwualuka the copy of where to buy the kits in Lusaka that I had printed and taken with me from Canada.
        Unfortunately I don’t think he can afford to go to Lusaka as he purchases the supplies to sell in his shop from Kalabo and occasionally from Mongu. So if/when you have a wholesaler in Mongu and/or Kalabo I would love to know and I will pass on the message so Mwualuka ( & his wife) can purchase the kits to sell in their shop.
        I will inform my contacts in Lundazi and Chipata that there is a wholesaler coming soon. If you don’t mind could you let me know who that wholesaler will be so I may pass it along. Keep up the great work and thanks for the training you are giving me as well. Best, Joanne

  3. I think this is an interesting conversation because it comes down to two issues that often exist in opposition to one another, but that shouldn’t: health impact vs. sustainability. A public health perspective typically seeks to maximize health impact – lives saved, deaths averted. And seeks to do it by whatever means necessary. Therefore, an important market for Kit Yamoyo would necessarily be institutional buyers, whether government or private not-for-profits, such as NGOs, who would then provide the Kit free to their constituents.

    The main issue with this, however, is that it makes access to the Kit somewhat dependent on projects/programs and their financing streams. You may maximize health impact and save lives in the short term….but what happens when the project goes away, or when the NGO has a turnover in staff, or when the funding cycle ends?

    It is something that should give NGOs and public sector pause for thought. Because if they cannot guarantee a sustainable, consistent, long term supply to patients – and, moreover, if providing certain medicines free (that would otherwise, like ORS, be available and affordable “over-the-counter”) ends up distorting the retail market for those over-the-counter medicines – then they actually don’t save lives in the long term. They buy short term health impact – individual lives saved now – at the cost of deaths averted in the future.

    Personally, my opinion has always been that once Kit Yamoyo is turned over to a local manufacturer, then that manufacturer should free to sell it to whomever it wants to sell it. If NGOs or public sector procurers want to buy it, and provide it free of charge to their constituents, then it is their right to do so (and the manufacturers right to sell to them), as this is just another aspect of the market. Its not something that should/can be regulated or controlled by ColaLife or anybody else.

    But the larger point that Simon makes is an important one: there is no long term health impact without sustainability. And sustainability means effective and efficient supply chains for essential medicines. For essential medicines that are effectively classified as “over-the-counter” medicines (i.e. that private retailers are legally entitled to sell), one such legitimate and critical supply chain in this process of creating access is that of the private sector.

    Its obviously not for everything. You can’t turn TB or AIDS drugs over to it. And you will definitely not want to turn malaria drugs or antibiotics over to it without proper regulation. But ORS/Zinc combination therapy is an essential medicine for which access via the private sector not only makes sense, but also may make a massive difference in terms of lives saved/deaths averted not today, but 10 or 15 years down the line.

    So ColaLife, from the narrow public health perspective, yes, may very much be a “preventing children’s deaths from diarrhoea” project. But from the big-picture-perspective, it is actually much more than that. It is instead a systems strengthening project. In that respect, the disease, the lives the disease claims, the commodity, and the lives the commodities saves, are secondary. What matters more – it seems to me – is creating a process to make it all work, over time, without dependency on external sources.

    On the recommendations: two things. First, I feel that they could be reworked slightly to make them actionable. First of all: Who? Who is to ’embrace’? Who is to promote? Who is to make ORS/Zinc available? Who is to raise awareness? Who is carrying out para-skilling? Who are the recommendations targeting? Are they meant for government? Are they meant for NGOs? And how should “they” do all this? What – in a broad sense – needs to happen to make ORS/Zinc available in all health centres? Or to para-skill retailers? Obviously, recommendations are not an appropriate place to go into great detail. That said, it seems that there needs to be a clearer link between “recommendations” and the “who” “what” “when” of actions, in order to take the recommendations from being observations/opinions, to being policy-relevant and operational.

    I think too – like the first person commenting – that “promote” and “raise awareness” are the same thing in many ways. And also that the words “promote” and “raise awareness” can be tightened and made, again, into something more concrete. What do you mean by “promotion”? What do you mean by “raising awareness?” These terms are a bit fuzzy. “Para-skill”, by contrast, is not. Its an activity. Its clear what this is. But “raising awareness” could mean anything or nothing. So I would just think these more general terms through a bit so that the recommendations have more weight.

    Otherwise: I love you guys!

    Beth

    • Magdalena Serpa says:

      Simon and Jane,

      I have two questions and one comment

      1. Name of country entity that oversees the quality of the products/local manufacture?
      2. Do you foresee need for mechanisms to prevent/control counterfeit?

      Comment to 5 immediate recommendations:

      It is great that breastfeeding is included. Did you consider expanding to cover other feeding recommendations?
      (I quote) BMC Public Health. 2013;13 Suppl 3:S17. doi: 10.1186/1471-2458-13-S3-S17. Epub 2013 Sep 17.Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review.
      Gaffey MF, Wazny K, Bassani DG, Bhutta ZA.

      CONCLUSIONS:

      Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847348/

      With regards and admiration!
      Magdalena