Design like you give a damn – the case for 200ml ORS sachets

This blog post has been gestating for a while but the contractions really started* when I read this tongue-in-cheek post – Designing the least user-friendly products imaginable – which was highlighted by Euan Semple in his Facebook timeline. This mug was one of the least-friendly designs highlighted.

Badly designed cup
Image credit: Designing the least user-friendly products imaginable just for fun

There was another push when Twitter informed me last week that Cameron Sinclair had started following us at Unlikely Alliances (@U_Alliances). Cameron Sinclair is a co-founder of Architecture for Humanity, a charitable organisation which seeks architectural solutions to humanitarian crises and brings professional design and construction services to communities in need. I first came across Architecture for Humanity through the design route when they launched their ‘Design Like You Give a Damn‘ (DLYGAD) initiative. DLYGAD was much more broadly focussed than architecture and is based on the premise that “Good design is not a luxury, but a necessity”, a statement that we would subscribe to.

So, did we give a damn in our design of the Kit Yamoyo? We took what felt like a huge risk during the set-up phase (Dec-11 to Aug-12) of the ColaLife trial when we decided we needed our own 200ml ORS sachets because the standard one litre sachets were inappropriate for the home treatment of diarrhoea. We found this out by talking to our target customers: carers, mostly women, wanting to treat a sick child at home.

One litre sachets of ORS are not quite as daft as the funny-looking mug shown above: any ORS can be a life-saver. But here are a few reasons why they don’t make sense for home use, if your objective is good health outcomes:

  1. A one litre sachet of ORS makes up one litre of solution, but in 24 hours an under 5 child will drink 400ml, on average
  2. Once made up the solution should be discarded after 24 hours (it says so on the ORS sachet) due to the high risk of the solution becoming contaminated if kept for longer
  3. This means that, if you follow the instructions, you throw away more solution (600ml) than you use (400ml)
  4. It also means that you can only treat your child for 2 days (if you follow the instructions) and our trial showed a longer period of treatment is usually needed
  5. We found that only 60% of mothers get the mixing right when given a one litre sachet (93% got it right when using the 200ml sachets in a Kit Yamoyo where the packaging acts as the measuring device for the water)

When we point this out to people in the public health sector many agree that it is not a good situation, yet the practice continues. Why? These are some of the reasons given:

  1. It’s always been done this way
  2. To have different sized ORS sachets would complicate things from a manufacturing and prescription perspective
  3. ORS is so cheap that wastage doesn’t matter

These are all valid reasons but, excuse me for pointing it out, these are all driven by the needs of the providers of ORS, not by the demands of users. This needs to change if we are to improve the treatment of diarrhoea and reduce child mortality.

Let’s put ourselves in the situation of the mother with a sick child just for moment and try an imagine how it feels when you are given 2 one litre sachets of unflavoured ORS to treat your child. Also, bear in mind that you may have to start treatment at night, in the dark:

  1. You will have difficulty finding a vessel that measures one litre (our trial showed that 40% will get the measuring wrong)
  2. You are likely to have difficulty sourcing a whole litre of water. Bear in mind that in most circumstances the water will have been carried to the home and will have needed to be treated (boiled usually) to make it safe
  3. The ORS solution will be very unpalatable and you will struggle to get your child to drink it
  4. After 24 hours you will need to throw away what’s not been consumed and start again with the second sachet

Aside from these practical challenges, how would you feel as a mother? Would you feel you were doing the right thing? Would you feel you were doing the best thing for your child?

During the 12 months of the ColaLife trial, mothers’ perception of ORS as an effective treatment for diarrhoea went up from 78% to 92% – 14 percentage points. The public health sector might consider 78% as “good enough”. But it’s not good enough when it can so easily be increased to 92% by the simple act of listening to mothers and giving them what they ‘want’, not what you think they ‘need’.

Going back to the inappropriateness of the one litre sachet for the home treatment of diarrhoea for a moment. I’ve already pointed out the wastefulness of current practice, the fact that so many mothers are getting the mixing wrong and how it may be affecting the way they feel about doing the right thing. But let me add just one more thing, that should be of concern to those interested in improved health outcomes.

Giving a mother two one litre sachets, in theory, only provides enough ORS to treat for 2 days. You can see from the table below (from our endline survey) that mothers eke this out to 2.75 days. But this will come with the risk of contamination. However, when mothers are given 200ml sachets, there is no wastage and they treat their child for longer (3.55 days). Giving less total ORS, but in more appropriate sachet sizes, increases the number of days mothers are able to treat their children.

Average days of ORS use
All non-Kit Yamoyo users at Baseline used one litre ORS sachets. All Kit Yamoyo users used 200ml ORS sachets.

If we look at the number of 200ml sachets mothers used, it gets even more interesting. The graph below shows that 80% of mothers used 4 x 200ml sachets or less. Then there is a blip in the data where 10% of mothers used all 8 of the sachets provided in the trial kit. We think these mothers used 8 sachets, not because they needed to, but because 8 sachets were provided. If you accept this, then 90% of women used 4 x sachets or less – that’s equivalent to a total of 800ml of ORS solution and yet standard practice is to give them 2 one litre sachets. Through western eyes this looks like a waste of ORS, through a mother’s eyes it looks like a terrible waste of safe water.

Number of ORS sachets used (average over both districts)
Non-Kit Yamoyo users at Baseline all used one litre sachets of ORS

So, are one litre ORS sachets for the home treatment of diarrhoea one of the least user-friendly health product designs?

And if they are, then does it matter?


A note on the data in this post

The data contained in this blog post are unpublished and based on preliminary analysis of data from the ColaLife Operational Trial in Zambia (COTZ). Final calculations may vary and will be published in peer reviewed literature in due course. In the interim, the following citation may be used: Ramchandani, R. et al. (forthcoming). ColaLife Operational Trial Zambia (COTZ) Evaluation. Johns Hopkins Bloomberg School of Public Health, Baltimore. Related correspondence should be sent to Rohit Ramchandani ( and copied to Simon Berry (

Update on publications, 2022

Since this post, a number of publications, including peer reviewed, drawn from the COTZ Trial and subsequent learning, have come into the public domain and underpin the evidence and ideas in this blog post. See:

  • COTZ Endline Evaluation Report, commissioned by UNICEF Zambia, authored by Ruralnet Associates and published by DfID on the UK Government website is here.
  • Doctoral Thesis by our Principle Investigator, Rohit Ramchandani Dr PH, is published by John’s Hopkins University here.
  • Article on Emulating Value Chains, published here by the British Medical Journal.
  • An article on Institutionalisation and Vertical Scale UP of Innovations is in preparation. Future link to be added.
  • An article on Design Thinking and its application by ColaLife to ORS and Zinc co-packaging is in preparation. Future link to be added.


* Apologies for this metaphor but I’m an expectant Grandfather, and I’m on call, so such things are uppermost in my mind at the moment.