**CURRENT STATUS**

Last updated: 15-Oct-18
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Latest changes in blue.

ColaLife team deployment:

Simon Berry – part-time – in the UK working on our WHO Essential Medicines List application.
Jane Berry – part-time in the UK working on future strategy and finalising the KYTS-LUSAKA project.
Rohit Ramchadani – part-time – Canada – working on WHO Essential Medicines List application.

 

There are four threads to our activity:

  1. SCALE-UP
    The donor-supported market development projects in Zambia have come to an end. The two donor-supported projects were called KYTS-ACE and KYTS-LUSAKA. These sought to increase access to to co-packaged ORS and Zinc for diarrhoea treatment in remote rural areas and Lusaka Province respectively. The results of the endline surveys for both projects are in and have been shared with our Stakeholder Learning & Steering group in Zambia and on our blog. We hope that we have done enough to establish Kit Yamoyo and its public sector version – the GRZ ORS/Zinc co-pack – in the private and public sectors. We are now in a completely “hands-off” phase, with the manufacturer selling directly to the market – we have an agreement with them that we can monitor their ex-factory sales. >> jump to the detail
  2. GLOBALIZATION
    We developed a Globalization Strategy in 2016 as part of the Ashoka Globalizer programme on Light and Health sponsored by the Philips Foundation. to seek impact beyond Zambia, but without growing ColaLife. The first draft of our strategy was presented in Eindhoven on 19-Oct-16. We decided in 2018 to grasp the opportunity to work with partners to get co-packaged ORS and Zinc on the WHO Essential Medicines List for Children (see item 4). In the meantime we are liaising with interested partners and inviting people to contribute to our globalizer knowledgebase here.
  3. CAMPAIGNING AND DISSEMINATION
    We are working to influence the big players in global health, as well as other manufacturers. We want others to adopt and adapt key lessons and design benefits, which we believe will help increase home use of ORS and Zinc for under-5 diarrhoea. Our three main messages are: smaller ORS sachets are better for home use; make packaging both attractive and functional, especially co-packaging ORS with Zinc and enabling easy measuring of water to make up ORS solution; desirable, affordable and profitable products will reach even remote communities. >>jump to the detail
  4. CO-PACKAGED ORS AND ZINC ON THE WHO ESSENTIAL MEDICINES LIST FOR CHILDREN
    We have assembled a team from the Diarrhoea Innovations Group (DIG) and are working on an application to WHO to add co-packaged ORS and Zinc to the WHO Essential Medicines List for Children (EMLc). This could help bring about a step change in access to co-packaged ORS/Zinc all over the world.  Our application needs to be submitted by Nov-18 and will be considered by the WHO EML Committee in Mar-19 with a decision expected in Jun-19. Please see this blog post for more information.

1. SCALE-UP

A trial of the ColaLife Model in 2012/13 increased diarrhoea treatment rates with Oral Rehydration Salts (ORS) and Zinc, the WHO/UNICEF standard, from <1% to 45% in remote rural areas of Zambia in 12 months (see Headline Findings of the ColaLife Trial in Zambia). This compelled us to keep the supply of ORS and Zinc going when the trial ended in Sep-13. It would have been unethical to stop the supply at the end of the trial as carers, mostly mothers, had got used to being able to buy ORS and Zinc in the form of an anti-diarrhoea kit, called Kit Yamoyo, from their local shop. We referred to the scale-up as KYTS (Kit Yamoyo Transition to Scale) and there were three threads of activity under KYTS:

  1. KYTS-ACE (Adapting to Challenging Environments)
  2. KYTS-LUSAKA – operating in the slums of the capital and some rural areas
  3. KYTS-FORMAL (Shoprite and other supermarkets, pharmacies)

KYTS-ACE got underway in Feb-15 and focussed on the 14 most nutritionally challenged districts in Zambia. In 5 of these districts worked with small retailers (like we did in the trial); 11 districts were supplied with a free, public sector ORS/Zinc co-pack, based on the Kit Yamoyo design, distributed through health centres. In 4 districts, we obtained distribution through Shoprite stores. In some of the 14 districts there was more than one distribution channel, so we could observe the effect of various combinations of channels. Both Kit Yamoyo (the commercial product) and the public sector ORS/Zinc co-pack are produced locally in Zambia, by Pharmanova. This work is supported by Zambia’s SUN Programme (Scaling Up Nutrition). Our partner KZF was invited to submit a proposal to extend this work until Dec-17. This was done with ColaLife’s support and an extension to Dec-17 was approved. This brought all 14 districts into the public sector part of the programme and extended the work with small retailers to six others bring the total to 10. KYTS-ACE came to an end on 31-Dec-17. The endline survey showed that the treatment rates with ORS and Zinc were 53% with 41% coming from Kit Yamoyo (either the commercial version or the private sector version). This compares vary favourably with the treatments rates of <1% that we found in the trial. For more detail of the impact of KYTS-ACE please see: We’ve got designs on change: 1 – Findings from our endline household survey (KYTS-ACE).

KYTS-LUSAKA launched in Oct-15 and is focussed on Lusaka Province: primarily on the townships (compounds) around the capital but also in 3 other, more rural districts. Work focussed on small grocery stores serving these densely populated areas but we also secured distribution through Shoprite stores, and some pharmacies. Shoprite started stocking Kit Yamoyo from Jan-16. This work is supported by UK Aid Direct (75%) and the balance of the funding comes from ColaLife’s own resources. KYTS-LUSAKA ended on 31-Mar-18 and immediately prior to that survey work was carried out to assess the impact. We are currently analysing these surveys and will report by the end of May-18.

KYTS-FORMAL covers activities with up to 30 Shoprite stores nationwide and started in Jan-16; there is some overlap with KYTS-ACE (4 stores) and KYTS-LUSAKA (7 stores). This thread of activity gives us outlets in the Copperbelt (the second largest populated area in Zambia) for the first time. As well as being important retail outlets, Shoprite stores also act as wholesalers for small retailers. This is a common model in Zambia: retailers from the townships and rural areas buy in bulk from Shoprite and re-sell in their own communities at a profit. Shoprite recognise this and have put no limits on bulk buying of Kit Yamoyo. They do have limits on bulk buying of other products. 

Progress towards scale-up Nov-15

The resources had, to move from successful trial to scale-up have varied enormously, as explained below, so the level of activity varied from district to district over time. In Nov-14 we had to shut down operations in Southern Province due to lack of funds. However, activities in Southern Province took a boost through our agreement with Shoprite who have two stores in the province (Mazabuka and Livingstone).

What do we mean by scale-up?
Scale-up is a one-off investment by donors and philanthropists to establish Kit Yamoyo in the Zambian market and within government. The scale-up has been delivered using ‘the ColaLife approach’ that we expect to ensure that access to Kit yamoyo and the public sector version is self-sustaining after donor support and the support of ColaLife comes to an end. The ColaLife approach dictates that ColaLife itself cannot become a permanent part of the solution. To do this we have worked exclusively through local organisations and processes so that the solution is embedded locally. We have developed Kit Yamoyo to be profitable for all those involved in getting it to carers. We know from the trial that once carers have used Kit Yamoyo they will 1) seek it out to use it again and 2) recommend it to their friends. We are learning from the market scale-up work in Zambia, so we can support other countries.

The key elements of the scale-up activity were:

  • Training retailers and Community Health Workers in product benefits and issues around diarrhoea
  • On-going support for newly trained retailers and Community Health Workers
  • Awareness raising among carers
  • Development of the distribution chain (recruitment of wholesalers and retailers)
  • Community-based marketing
  • Mass marketing
  • Identifying and ironing out bottlenecks in distribution and other issues arising.

Now that the donor-funded elements of the scale-up are complete ColaLife is in “hands-off” monitoring mode and we expect that no further donor funding, and no further input from ColaLife, will be required beyond this point.

The scale-up story
Moving from the original trial to implement our scale-up plans was not easy. We were not successful in raising the funds for a national scale-up to follow on seamlessly from the trial (see Grand Challenges Canada say “no”). However, two of the trial funders – DfID and Johnson & Johnson/Janssen EMEA – provided transitional funding. This enabled modest expansion of the retailer network in the trial districts (Katete and Kalomo) and a move into the trial control districts (Petauke and Monze).

A second attempt to raise funding for a national scale-up through USAID-DIV made good progress but failed at the final hurdle. By this time (mid 2013) the transitional funding was coming to an end. We faced other significant challenges during this time. In Nov-13 the KZF Office in Kalomo (Southern Province) had to be closed and staff were laid off and there has been no further scale-up activity in Southern Province since this time. At this point ColaLife injected £15,000 of its own reserves to keep activity underway in Katete (Eastern Province) while we waited for news on our KYTS-ACE bid which was approved on the second attempt. KYTS-ACE got underway in Feb-15 and is funded under the Zambian SUN* programme targeting 14 of the most remote and sparsely populated districts in Zambia (see above). These are not areas one would choose to scale-up a private sector product such as Kit Yamoyo. However, KYTS-ACE also supports Zambia’s Ministry of Health in the procurement of 452,000 ORS/Zinc co-packs for distribution through the public sector. This gave a massive boost to our pharmaceutical partner, Pharmanova. These ORS/Zinc co-packs contain the same ORS and Zinc components as the commercial product (Kit Yamoyo) and are delivered in the same packaging but do not carry the Kit Yamoyo branding. The first private sector kits (Kit Yamoyo) arrived in Central Province (Mumbwa) and Western Province (Mongu and Kalabo) in the week beginning 2-Nov-15. Project field staff have been trained in the use of the Android tablets using the CommCare system to track progress.

In Sep-15 we signed a contract with DfID, under UKAID Direct, to scale-up in Lusaka Province: the most densely populated province in Zambia. This project is called KYTS-LUSAKA (see above) and got underway on 1-Oct-15. The data collection phase of the baseline survey is now complete. 1,513 household surveys were carried out. The data has been cleaned and analysis is underway.

Finally, in Dec-15 Shoprite agreed to carry Kit Yamoyo in their catalogue, nationwide. This is hugely significant and gives us outlets in the Copperbelt for the first time. Kit Yamoyo started appearing in stores in Jan-16. This thread of activity is referred to as a part of KYTS-FORMAL.

Kit Yamoyo on the shelf in Shoprite (Mongu) Kit Yamoyo on the shelf in Shoprite (Chipata)
Image credits: Akufuna Ngenda (Mongu) and Elias Lungu (Chipata)

KYTS-ACE came to an end on 31-Dec-17 and KYTS-LUSAKA ended on 31-Mar-18.

The scale-up staffing
Keepers Zambia Foundation had the following staff in place:

  1. Headquarters (Lusaka):
    1. Project Manager – KYTS-ACE (from Feb-15 to 31-Dec-17)
    2. Project Manager – KYTS-LUSAKA (from 11-Jan-16 to 31-Mar-18)
    3. Four Field Facilitators – KYTS-LUSAKA (from 10-Feb-16 to 31-Mar-18)
  2. Central Province (Mumbwa)
    1. Field Facilitator – KYTS-ACE (from Feb-15 to 31-Dec-17)
  3. Eastern Province
    1. Project Officer – KYTS-ACE (from Feb-15 to 31-Dec-17)
    2. One Field Facilitator – KYTS-ACE (from Feb-15 to 31-Dec-17)
  4. Western Province
    1. Project Officer – KYTS-ACE (from Feb-15 to 31-Dec-17)
    2. Two Field Facilitators – KYTS-ACE (until 31-Dec-16 and then one field facilitator from Jan to Dec-17)
  5. Luapula Province
    1. Field Facilitator – KYTS-ACE (from Feb-17 to 31-Dec-17)
  6. Northern Province
    1. Two Field Facilitators – KYTS-ACE (from Feb-17 to 31-Dec-17)

These staff are supported part-time by a KZF Programme Manager and the Accounts Team, as well as by ColaLife staff.

What impact do we expect to have?
We know from many studies that increased use of ORS and Zinc saves lives and reduces stunting in under-5 children. Academics used the Lives Saved Tool (LiST) developed by Johns Hopkins School of Public Health to estimate the lives saved during the ColaLife trial and concluded that 3 lives were saved per 1,000 kits used. We are working for a sustainable impact and our target is to halve diarrrhoea deaths in Zambia by 2020 (2,500 lives saved per year – on an ongoing basis). As an illustration, with current prevalence, this would mean 850,000 ORS/Z kits are used per year.

Kits sold so far
From the start of the ColaLife Trial in Aug-12 to the end of 2017 124,650 Kit Yamoyos were sold and 452,000 ORS/Zinc co-packs were supplied to the Ministry of Health.

Kit Yamoyo sales 2012 to 2017

The ColaLife Model
There are three key elements to the ColaLife Model which have delivered very big increases** in the use of ORS and Zinc for the home treatment of diarrhoea. These are:

  1. An anti-diarrhoea kit which carers WANT which is:
    1. Aspirational
    2. Affordable
    3. Profitable
  2. Better product design, to meet users needs
  3. Effective marketing

Our approach is distinctive too:

  1. We involved carers in the design of Kit Yamoyo anti-diarrhoea kit so that we produced a product we knew they wanted not something that we thought they needed.
  2. We use a price minus costing approach rather than a cost plus pricing approach. That is to say, we start with what customers tell us they are willing to pay and work backwards from that, seeking to reduce costs to achieve the profit margins required for all those in the manufacturing and distribution chain while maintaining affordability for the customer.
  3. We applied subsidies sensibly so as to strengthen, not undermine, existing distribution channels and establish a viable value chain. We did this in two ways:
    1. When first launching the Kit Yamoyo product we gave vouchers which carers could exchange for a kit in their local shop. This kick-started the value chain and provided the initial incentive for retailers to seek out wholesale suppliers of the kit and bring it to their community.
    2. During the trial we were unable to get the costs down low enough to ensure affordability and provide adequate margins for those manufacturing and selling the kits. To overcome this we injected a subsidy at the top of the value chain so that the price points achieved along the value chain (the ex-factory price, the wholesale price and retail price) were those that we were aiming for in the long term (once costs had been reduced and the subsidy removed). Subsequently, this subsidy has been removed by reducing the cost of production of the kit. This has been achieved by applying the learning from the trial and re-designing the kit to be lower cost. See How the ColaLife trial findings have influenced the design of Kit Yamoy0.
  4. We are focussing on sustainability. For us, this means everything is done through local organisations. ColaLife’s role is catalytic and temporary. For this reason ColaLife is not constituted in Zambia. Carers who buy the product and all those along the distribution chain are not aware of ColaLife’s existence. ColaLife’s branding appears nowhere (not even on the Kit Yamoyo). To be sustainable, ColaLife cannot be a permanent part of the system that delivers an affordable and aspirational anti-diarrhoea kit to carers in Zambia.

2. GLOBALIZATION

We want to grow our impact beyond Zambia as quickly as possible and hope to publish our plans for others to contribute to and comment on in early 2017. We aim to save 5,000 lives and improve 2 million others by 2020 and then, every year from 2021, save 5,000 lives and improve 1 million lives. Our approach will be to support others to take on the learning and findings from the trial and scale-up in Zambia and apply this to their own circumstances. The following steps are envisaged in our globalization plan:

  1. Identify the 10 countries with the highest number of diarrhoea deaths
  2. Establish a “smart network”, or “national alliance” in at least 6 of these countries around the vision of: Saving lives and reducing stunting through better access to ORS and Zinc for the treatment of diarrhoea.
  3. Support this “smart network” to achieve this vision including providing access to our designs, processes, findings and learning on an open source basis. See colalife.org/openaccess.

3. CAMPAIGNING AND DISSEMINATION

Campaigning
In parallel with the scale-up effort we are campaigning for:

  1. The increased global availability of 200ml ORS sachets for the home treatment of diarrhoea. See: The case for 200ml ORS sachets.
  2. The co-packaging of ORS and Zinc. See: The case for co-packaging ORS and Zinc.
  3. Over-the-counter status for ORS and Zinc so that it can be sold through ordinary retailer outlets. This is already the case in many countries but there is work to do in others.
  4. People to understand that all ColaLife’s designs, learning and findings are available for free for anyone with a responsibility for child health. See: ColaLife’s Open Access Initiative.

Dissemination
ColaLife could not grow quickly enough to have the impact we seek. In any case, the organisations are already in place globally and nationally with a mandate and responsibility for children’s health. So, our strategy for global impact is to influence the strategies of others so that they apply our designs, findings and learning to their own circumstances. We are helping this process through our Open Access Initiative.

As the scale-up gets underway we will be able to apply more resources and become more strategic and proactive in our campaigning and dissemination activities.

In Apr-16 we were accepted onto the Ashoka Globalizer programme and we are working with a external team of specialists with expertise in the scaling up of social impact beyond Zambia.

Funders
We are immensely grateful to the majority funders of our current projects (SUN programme, including DfID, and DfID’s UK Aid Direct fund) and especially to funders who have come on board in the last year, to offer vital core funding that we can use freely in creative ways. This has put ‘match funds’ on the table to win our two current projects, and enabled us to devote ourselves full-time to all aspects of the ColaLife mission: A huge thank-you, then, to The Isenberg Family Trust, GSK/Save the Children Innovation Award, all of our Global Giving donors in UK/Europe, the USA and beyond, our sponsorship by Everly, and the Ashoka Network.

Supporters
Form the outset ColaLife has depended on the support of hundreds of people who have put in time, expertise and other resources. We are very grateful to them all and have tried to list everyone here (if your name’s missing please let us know!).

 

 

* SUN = Scaling Up Nutrition

** In the ColaLife Operational Trial in Zambia (COTZ), over a 12 month period, ORS/Zinc treatment rates increased from <1% to 45% in children with diarrhoea in the last two weeks. See Seven of the headline findings from the ColaLife trial in Zambia.