In the COTZ trial, we were focussing on finding out how we could reach children in rural villages with ORS and Zinc, to stop children dying from diarrhoea. By early 2014, we were planning an expansion into urban areas. Crucially, the learning from the trial had forced us to completely revisit the kit design and rationalise the contents, reducing costs and localising packaging production as much as possible. Would this affect willingness to pay? We decided to run price trials again, this time focussing on some of the urban areas where we hoped to start a country-wide scale-up.
IDInsight, who had already done an in-depth Willingness to Pay study for us in rural Monze, proposed to run a similar study for us in the Copperbelt.
The study ran from February – March 2014 and the methods were essentially the same as they had used the previous year – although the product was now in different formats, based on our overhaul of the Kit Yamoyo designs after the trial: a simple flexi-pack and a screw-top jar. IDInsight ran two separate research arms to cover these two new formats, with 209 and 216 participants respectively. In all, 29 sessions were run, in the vicinity of 6 Health Centres in Kitwe and 4 in Ndola.
What was really striking in this study, is not only that the ‘sticky’ price point was yet again 5 Kwacha (approx 1 US Dollar) – the same as in the previous rural study and in our pre-trial Focus Group work – but that the demand curves for the screw-top jar (a premium product) and the flexi-pack were remarkably similar. That meant that the study recommended 5 Kwacha for each of the formats. Both we and the researchers were surprised by this.
Again, there was a large proportion of participants (60% for the Flexi-pack and 64% for the Screw-top) who felt they could not pay more than 2.50 Kwacha, pointing to a need to develop free provision of Kit Yamoyo via government health centres, for those able to travel and willing to queue.
In comparing the rural and urban studies, another surprising finding was that rural communities were willing to pay 1 Kwacha MORE than urban communities. We do need to recognise that, because we were at different stages in production and commercialisation, different format products were offered; the original Kit Yamoyo trialled in rural Monze, for example, had 8 small sachets of ORS instead of 4. However, the researchers also considered that in rural areas, the trip to a clinic for a free supply was a more difficult option: rural clinics are usually much further away from many caregivers, transport is sketchy, walking a long distance with a sick child is risky and rural clinic stock-outs are more common.
What all of our delving into the investigation of Willingness to Pay has taught us, is that affordability is much more complex than most people imagine. Although people may be cash poor, the option to be able to buy an effective, high-quality product locally is not something they would discount entirely. Five Kwacha (about half a day’s income in poor areas) comes up time and again as a choice people are willing to make – particularly given the uncertainty of free supply in government clinics coupled with long travel distances or wait times and out of pocket expenses when away from home. However, a reliable, free supply through the Ministry of Health is something we – and our local commercial partner, Pharmanova, should work on in future.
Update: By the time we left Zambia in late 2017, the Ministry of Health had adopted co-packaged ORS and Zinc on their Essential Medicines List and was regularly ordering a government-branded ‘Kit Yamoyo’ flexi-pack from Pharmanova – thus offering a free supply in many rural and urban health centres.
