Why isn’t co-packaged ORS and Zinc on the WHO Essential Medicines for Children?

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In the evening of 28-Jan-17, four days into our latest support trip to Zambia, the penny dropped. Why isn’t co-packaged ORS and Zinc on WHO’s Essential Medicines List for Children (EMLc)? Oral rehydration salts are listed. Zinc is listed. But the global recommendation of ORS and Zinc together is not listed.

To quote WHO:

Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.

Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford.

The WHO EML has a big influence on health policy, with most countries following WHO’s lead, modelling their own Essential Medicines List on that recommended by WHO.

So I sent this email to the e-drug mailing list to outline the case:

Dear e-druggers, your views on this please.

We have an international recommendation for the treatment of diarrhoea which is now 12 years old (WHO/UNICEF). The recommendation is a combined therapy of Oral Rehydration Salts (ORS) and Zinc. This recommendation covers home treatment and treatment in institutions.

12 years on, 99% of diarrhoea cases are NOT treated with ORS and Zinc and diarrhoea remains the second biggest infectious killer of under 5 children.

It is clear from our work, that while ORS and Zinc are listed as separate items on the Essential Medicines List (EML) they will be supplied separately and very rarely dispensed together (as per the international recommendation). There are several reasons for this and these include:

  1. The supply of ORS and Zinc may be unbalanced so that either or both may be out of stock (see below)
  2. In resource-poor situations there may be a tendency to hold back Zinc for cases judged to be ‘severe’ and so Zinc is not given as a routine (when it should be)
  3. The person dispensing may not be aware of the correct treatment
  4. When ORS and Zinc are distributed separately, there is less chance that they will both be in stock at the same time. If the stocking rate for ORS is 50% and the stocking rate for Zinc is 40%, the stocking rate for both will be just 20%.

Having them as separate items on the EML also means that those procuring ask for one and not the other. Let me give you an example:

In Zambia the Ministry of Health asked UNICEF to help with the supply of ORS. Without questioning this request, UNICEF supplied. So we went from a situation where there was no ORS and a situation where there was plenty. At this time a local pharmaceutical company started shipping an ORS/Zinc co-pack to the Ministry [I’m referring to the GRZ co-pack here] but some health centres said they couldn’t accept it as they had so much ORS. So in effect UNICEF undermined its own recommendation by flooding the ‘market’ with ORS only.

So, my question is, can we include co-packaged ORS and Zinc on the EML? And if not, why not?

In my opinion, if we did this, it would transform the prospects of getting the recommended treatment for diarrhoea to under five children and would save thousands of lives.

I am very interested to read your comments.


I received one or two supportive emails following this and one included the comment, “I can’t believe this hasn’t been suggested before”.

It’s often the obvious that’s missing. You just have to notice it.

So, buoyed by this, I attempted to find out who managed the EML process. I found that it was a Dr Nicola Magrini. I emailed Dr Magrini but got no response initially so I called the WHO switchboard in Geneva and on my third attempt I got through to Dr Magrini’s voicemail.  I asked him to please respond to my email, which he did.

This was followed with a Skype call with Dr Magrini, involving Jane, Rohit and Dr Fundafunda – a founding supporter of our work in Zambia and the ex-Managing Director of Medical Stores Limited. During this call, Dr Magrini gave his advice on how to proceed – we’re now following this.

We hope that Zambia’s Honourable Minister of Health will write to the EML Committee asking them to consider this simple proposal:  Please include co-packaged ORS and Zinc on the EML.

The EML Committee meets just once every two years and the next meeting is 27 to 31-Mar-17. If we miss this meeting we will have to wait for another two years.

Watch this space.




  1. Via email says

    Good luck, Simon and Jane!! Glad your call went well and wishing you much success with the EML Committee meeting soon!