The 11 As for Access to ORS & Zinc for Under-5 Diarrhoea Treatment

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Access to essential medicines is seen as the key barrier to health in developing countries, by governments and corporates alike[1]. The pharmaceutical industry and those involved in delivering patient healthcare often frame the issues surrounding ‘access’ as three – or sometimes four –  ‘As for Access’. ColaLife has looked at models of patient access covering, for example: Availability, Affordability, Acceptability and Adherence. Diarrhoea is the second biggest killer of children under 5. We know how to treat it: with ORS and Zinc. This is cheap, easy to transport medicine is usually ‘over-the-counter’ – not requiring a pharmacy to dispense. As only 1% of children in Sub Saharan Africa, including Zambia, got this treatment when we first started our work, we’ve tried to build on previous ‘Access to Medicines’ frameworks, based on our learning in Zambia. We came up with 11 As for Access developing a local market for Kit Yamoyo – an innovative ORS/Zinc co-pack.

1. Ask your customer

ORS and Zinc as a combination therapy have been recommended for diarrhoea by WHO/Unicef for a decade. Yet, until ColaLife re-visited conventional ORSZ co-pack design in 2011, no-one had actually asked carers in the developing world what they wanted, and adapted ORSZ design to what their situation required.

A number of conventional ORSZ ‘co-packs’ (usually 2 x 1 litre ORS sachets and 10 Zinc tablets in a printed cardboard box) are on the market. Some have been trialled by NGOs[2] as part of behaviour change to promote ORSZ among carers of under-5 children.

Asking your customer is vital: customer consultation, participatory research, market research, ‘human centred design’ – these are different ways of expressing a similar underlying requirement for success, whether in the public or private sector: Don’t assume you know what they need; ask your customer (or beneficiary) what they want. This means exploring what issues and problems they have, including with current products or services.

ColaLife’s focus group work explored carers’ knowledge and fears about diarrhoea as well as challenges and preferences. This gave us a wealth of insights, including some key design findings:

  • conventional 1 litre ORS sachets are too big for home use (they were originally arbitrarily designed at 1 litre for institutions);
  • a child normally drinks 200ml to 400ml a day; beyond 24 hours, ORS solution should be discarded;
  • a litre is poorly understood in Zambia, and few households have suitable measuring vessels;
  • mixing small amounts is also preferred to avoid wasting water, usually carried long distances.

We also asked carers about preferred branding – including the product name – and pricing and affordability (see below).

2. Adaptation

Adapting a product (or service) and its delivery as far as possible to the context can help improve access. Adaptations might include functional, aesthetic, cultural or regulatory aspects.

Key adaptations for Kit Yamoyo included:

  • a number of design benefits (see ‘Advantage’)
  • an easy-to-understand graphical leaflet to give carers confidence in correct home use
  • branding and messaging adapted to cultural preferences or sensitivities
  • alignment to the regulatory and policy landscape

Adaptation may be iterative: we began by including 8 x 200ml ORS sachets in one pack (to closely align with the 2 x 1 litre convention) until we found, through the COTZ trial, that carers were only using 4 sachets per diarrhoea episode (ie 800ml – less than half of the ORS typically prescribed).

The Kit Yamoyo pack is designed to support further adaptation: the see-through packaging allows branding and messaging to be carried on a paper insert, for easily-adapted changes in branding (eg public and private sector; different languages; transfer to a different country).

However, one of our adaptations for improved access (ie designing the kit packaging to fit in the unused space in cola crates) was not, the COTZ trial showed, an actual advantage (see Advantage below). The latest iteration, based on lessons from the trial, offers a light-weight, compact, plastic ‘flexi-pack’ – which can still measure water but is easy and cost effective to transport at volume.

In Zambia, ORSZ was already recognised in policy, but in some countries adaptation might lead to the need for advocacy.  See below.

3. Advocacy

Working with Ministry of Health and/or the regulatory body or powerful lobby groups (such as pharmacists) may be needed, if what customers want does not fit in with the current policy and regulatory framework. For example, ORSZ co-packs may not be on the Essential Medicines List – which means government budget lines can not be easily allocated. Zinc tablets may be listed as a medicine, not as a micro-nutrient, which may mean it cannot be sold ‘over-the-counter’ in general stores.

Advocacy extends to working with key influencers, eg traditional leaders, pharmacist and doctors associations, Community Health Workers, and retailers.

4. Advantage

Any new product must offer tangible new advantages to succeed. From a marketing view-point this means ‘selling the benefits’ to customers. But we find the advantages need to be analysed and communicated more widely: to the public health sector (including government and those dispensing at the front line – see Advocacy); and to private sector players in the value chain (eg profit they can make; their part in helping their community to be healthier).

For customers/beneficiaries, Kit Yamoyo’s product design advantages are:

  • pack size/dosage: 4 x 200ml ORS sachets, better suited to home use; 10 Zinc tablets, scored for easy halving (for children under months)
  • ease of use: the outer pack can be used to accurately measure 200ml of safe water
  • clear, graphical usage instructions on mixing and on the ten-day regimen for Zinc

For the public health sector, advantages include:

  • easy to provide ORS and Zinc simultaneously (typically, ORS may be in stock, but Zinc is not)
  • easy to explain correct use
  • can refer to local shop if not in stock (complementary distribution/variety of channels to market)
  • private sector availability means pressure is reduced on clinic queues
  • potential for local (in-country) manufacture/production (shorter lead times, less risk of expiry, lower costs, more certainty in costing/pricing – less exchange rate exposure, creation of jobs)

For the private sector, advantages include:

  • acceptable profit margin
  • we link up retailers and wholesalers
  • vouchers to stimulate early sales and create retailer confidence.
  • Training for micro-retailers and encouraging their pride in new knowledge
  • Serving their local community better

5. Aspiration (& Appeal)

The poor deserve good design just as much as the wealthy. A diarrhoea kit can be beautifully designed. We wanted to establish Kit Yamoyo as a high quality, desirable – even aspirational – product. ‘Affordable’ (see 8) doesn’t mean the product should look second class or ‘cheap’. Developing country customers want to know they are buying quality products that look good.

  • Glossy pack
  • Full colour branding
  • Photo-realistic logo (loving mother and her child)
  • Strap-lines linked to wisdom in caring for the child (confidence this is the right thing to do).

6. Awareness

In a developing country situation, ‘awareness’ means more than just advertising – there is an education piece to be done at all levels, to develop the value chain. This is more than the private sector could do or justify to launch a new product, so we argue it needs donor funding. Awareness development for Kit Yamoyo included:

  • Visits and presentations to key health staff (provincial and district Medical Officers)
  • Training selected health facility staff and community health workers in the new product and its benefits – to get buy-in from them and ensure they recommend the product to patients
  • Training micro-retailers in selected areas, so they can advise and promote to customers – and so they know where to get the product
  • Community drama, demonstrations and talks at events and venues such as Health Centre Child Health Days, in market places, at church/school/community events.
  • Radio slots, jingles and phone-in programmes

7. Acceptability

Acceptability flows from good Adaptation and can be supported by Awareness raising. As well as ‘conventional’ acceptability factors, such as taste/palatability, smell, size and shape, ease of swallowing, dosing frequency, presentation in the packaging, the administration device and so on, we found issues around:

  • Colour (of the branding): some rural Zambian communities associated red with evil/danger and would not buy or use on principle (until awareness sessions and advocacy with traditional leaders were undertaken)
  • Both the carer and the child must find the product acceptable. Children were attracted by the orange colour of the ORS: mixing in a clear container (eg the packaging provided) allowed them to see the colour disperse.
  • A preference among carers for ‘pills’ over just ORS powder (ie Zinc tablets were welcomed)
  • Zinc pills on the market were bitter-tasting, hard and quite large for children to take. We worked with the manufacturer to replace them with dispersible, flavoured zinc
  • Confidence: knowing the product is backed by government and health centres helped customers accept it

8. Affordability

Zambian customers (even the poor) will pay for a product in a retail setting if they are confident it is the right thing to do (see Awareness and Aspiration). We undertook willingness to pay studies and ‘reverse engineered’ the costings required, to achieve the optimum acceptable retail price (5 Zambian Kwacha at 2013 prices). In other words, instead of using the traditional ‘cost plus’ pricing model, we used ‘price minus’ costing. This meant significant cost reductions in the original design and presentation which we think we have achieved with the ‘flexi-pack’, with minimum sacrifice of the key advantages (ie ‘benefits’). Affordability has to work at every step of the value chain – not just for end-use customers.

9. Availability

Availability at the retail level for Kit Yamoyo relied on establishing a ‘pull’ factor. This was a combination of:

  • Awareness raising at all levels of the value chain and among wider stakeholders (see Awareness)
  • The profit motive (Advantage)
  • Establishing the value chain, and filling gaps, so that wholesalers know the product and where to buy it, and retailers know which wholesalers will stock
  • Vouchers helped create the necessary ‘pull’ in early market establishment (Affordability) and create availability – leading to confidence in the market
  • Constant reminders/sales and support calls helped keep retailers engaged (Advocacy/Awareness)
  • We used existing wholesale channels (starting with Coca-Cola wholesalers), as well as supermarkets, to plug the gaps we found at the wholesale level

10. Adherence

Product design – as well as education – can support adherence. The new small ORS sachets (200ml) increased correct use from ~60% to >90% during the COTZ trial.

We have now re-designed the Zinc pack, to try to achieve adherence to the recommended ten days’ use.

11. Analysis

Measure your impact/learn from what doesn’t work. Make sure the value chain keeps working!

 

Access is complex. We believe that considering these 11 As together can lead to improved Accessibility.

 

Useful links:

https://www.colalife.org/2012/09/22/katete-wholesaler-stocks-out-of-kit-yamoyos/

https://www.colalife.org/2013/03/03/its-the-value-chain-stupid/

https://www.colalife.org/2013/06/15/is-it-right-to-sell-ors-to-poor-people-when-they-could-make-their-own/

https://www.colalife.org/2014/05/04/5-immediate-recommendations-to-reduce-child-mortality-in-zambia/

https://www.colalife.org/2014/12/12/putting-the-live-back-in-delivery/

https://www.colalife.org/2015/03/27/a-big-question-for-the-big-pharma-companies/

[1] eg www.accaglobal.com/content/dam/acca/global/PDF-technical/health-sector/tech-tp-khcz.pdf  and www.accesstomedicineindex.org/

[2] eg Orasel in Myanmar by PSI International

[First published as a ColaLife Briefing Sheet 23-Jul-15]