EMULATING COMMERCIAL, PRIVATE-SECTOR VALUE-CHAINS TO IMPROVE ACCESS TO ORS AND ZINC IN RURAL ZAMBIA: EVALUATION OF THE COLALIFE TRIAL
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Globally, diarrhea remains a leading cause of avoidable morbidity and mortality in children under 5. The most pressing challenges and recommendations for the reduction of childhood diarrhea today are consistent with those described over the past decade, pointing to a need for innovation. Key challenges include insufficient access, production, distribution and promotion of essential commodities like ORS and zinc, the globally recommended treatments. Market-based solutions that engage the private sector and simultaneously stimulate both supply and demand of these commodities have been recommended as a way of increasing coverage, and ultimately reducing mortality. The ColaLife project aimed to emulate the commercial, private-sector value chains of fast moving consumer goods (FMCGs), like Coca-Cola, and apply similar principles to the development and introduction of an innovative diarrhea treatment kit called the Kit Yamoyo®. This dissertation explores key elements related to the establishment of an end-to-end value-chain for this new product in Zambia. It includes 1) analysis of the overall impact of the approach on uptake of ORS and zinc, 2) determining the effect of applying human-centered design to global health product innovation, and 3) a detailed description of commercial general stores to inform their potential as informal, community-level providers of public health commodities. The main data sources include cross-sectional, rural household surveys conducted in August of 2012 (baseline) and August of 2013 (endline), as well as retailer surveys conducted in March of 2013 (midline) and August of 2013 (endline). Questionnaires were administered to 2458 and 2477 caregivers of children under 5, across 4 rural districts of Zambia, at baseline and endline, respectively. Two districts (Kalomo and Katete) served as intervention districts, while the other two (Monze and Petauke) served as matched comparators. Paper #1 used a generalized linear model (GLM) with Poisson distribution to calculate the adjusted relative risk of combination therapy use in intervention districts vs. comparator districts at endline. Secondary analysis used difference-in-differences estimation to compare ORS use (with or without zinc) in the intervention and comparison districts, before and after market-shaping activities. Paper #2 compared ORS use in children under 5 with diarrhea who either used Kit Yamoyo or standard one-liter sachets of ORS from rural health centers. Data drawn from the endline survey were analyzed using logistic regression and calculated the odds of correct preparation of ORS (i.e. concentration) in Kit users vs. non-users. Secondary analysis examined to what extent preparation of ORS in the correct concentration, or other factors, was associated with a change in the odds of perceiving ORS as effective. Paper #3 is predominantly descriptive in nature. It used retailer survey data from 180 interviews of general, community-level retailers across the 4 study districts, who commonly sell FMCGs, to explore the potential of using them as outlets for provision of basic public health products like ORS and zinc. Findings were grouped under key themes including: infrastructure, staffing, ownership and operations, purchasing patterns, product preferences, and level of engagement with an intervention to expand coverage of a newly introduced diarrhea treatment kit. Within the span of one-year, use of ORS and zinc combination therapy in children under 5 years of age with diarrhea, increased from less than 1% at baseline to 46.6% across the intervention districts, while no change was seen in comparator districts. Difference-in-differences analysis comparing ORS use (with or without zinc) in the intervention and comparator districts, before and after market-shaping activities, found that ORS use increased significantly across intervention districts from 59.8% to 76.4%, while usage across comparators decreased non-significantly from 66.4% to 58.2%. In the intervention districts, there was a significant shift in point of access, from the public (originally the only point of access in rural Zambia) to the private sector, with introduction of the kit through community-level retailers. Rational use of ORS, defined as preparing and consuming ORS in the correct concentration, differed significantly between Kit Yamoyo users and users of standard one-liter ORS sachets. Kit Yamoyo, having been developed through a human-centered design (HCD) process resulting in smaller (200mL) ORS sachets and provision of a measurement vessel in the form of packaging, increased the odds of correctly preparing ORS by 10.93 times as compared to one-liter sachet users. Kit users prepared ORS in the correct concentration 93% of the time, while users of standard one-litre sachets prepared it in the correct concentration only 60% of the time. Secondary analysis found that correct preparation of ORS significantly increased the odds of perceiving ORS as effective, along with caregiver’s age and having heard a message related to ORS in the previous 3 months. In rural Zambia there exists a largely untapped potential to leverage community-level, general store retailers, who commonly sell fast-moving consumer goods (FMCGs) like soap, snacks and beverages, to expand access to select public health products (PHPs) like ORS and zinc. On average, these types of shops are open longer than rural health facilities. Retailers typically purchase goods multiple times per month, from multiple wholesalers, providing increased opportunity for supply when compared to the public sector. With 87% of rural general store retailers having been asked for advice related to diarrhea treatment, they are well placed to help address market demand. With an average gross margin of 29% across other FMCGs commonly sold by these retailers, margins on PHPs can meet the profit needs of the retailers by following suit and remain affordable for the majority of people. The leading motivational factors indicated by general retailers for carrying a PHP were helping children and their community followed by profit. Following the introduction of the Kit Yamoyo, 76% of retailers were found to have it in stock on the day of visit, improving upon stock rates at rural health facilities. Implementation of a value-chain approach for over-the-counter public health products, like a diarrhea treatment kit, can significantly improve coverage at the community level. Adopting a human-centered design approach in the development of PHPs and other public health interventions allows for great consideration of demand-related factors of access, such as acceptability, and can lead to improved product innovation, appropriate utilization and perceived efficacy, as well as a strengthened value-chain. Evidence that standard 1-liter ORS sachets are often being prepared incorrectly and administered without zinc, has important implications for design and optimal product presentation for diarrhea treatment. In addition, it implies that one of the standard global indicators used to measure progress in the treatment of diarrhea globally – coverage – may not be a completely accurate way of measuring progress. Measuring effective/rational use of treatments is vital when considering the details of implementation. Co-packaging of ORS with zinc and soap, smaller sachets of ORS (i.e. 200mL), packaging that doubles as a measurement vessel, and enabling access through community-level general retailers (which presumes ORS and zinc have over-the-counter status) are features of an effective product and value-chain for diarrhea treatment that can help enable greater access at the household level.