It has been interesting to see how different organisations have reacted to the establishment and imminent launch of the ORS/Zinc Co-pack Alliance (ORSZCA).
Some have said that, as far as they are concerned, it doesn’t really matter if ORS and Zinc is co-packaged or not, as long as diarrhoea cases are treated with both. TECHNICALLY this is totally correct and can’t be disputed on purely technical grounds. However, what’s important is what actually happens IN PRACTICE. On the ground, on the front line, co-packaging is crucial if our objective is to have more children treated with both ORS and Zinc. This is the primary reason that WHO now recommends that ORS and Zinc is co-packaged. The other reason WHO recommends co-packaging is that it is usually the cheapest way to deliver the 17-year-old recommendation that diarrhoea in children should be treated with both ORS and Zinc.
We have seen, over the last 17 years, what happens when co-packaging is not the norm. Before the change to the co-packaging recommendation in 2019 less than 7% of cases were treated with both ORS and Zinc even though this had been the recommendation since 2004. IN PRACTICE, when ORS and Zinc are not co-packaged, ORS and Zinc are procured separately, they are supplied separately and delivered separately and rarely dispensed together. There are a whole range of reasons for this, among them:
- One component might be out of stock – if there’s a 50% chance that either will be in stock at any one time then there’s only a 25% they will both be in stock at the same time.
- The person dispensing might not know that the recommended treatment is ORS and Zinc and only give one (usually ORS).
- In resource-poor situations it can ‘feel’ wrong to give two medicines to those who are first in the queue.
In 2015 a trial run in Ethiopia which bundled ORS and Zinc centrally or at health centre level, with appropriate messaging, increased adherence the recommended treatment (ORS and Zinc) from 72 to 86% (Gebremedhin et al (2016)).
In Zambia, management information contained in rural health centre reports from Mongu District was analysed to give an insight into the impact of co-packaging. Firstly, stock levels of both ORS and Zinc were investigated over two years (2016 and 2017) for the month of October – the usual peak month for diarrhoea incidence. Only 8 of the 30 health centres had both ORS and Zinc in stock throughout October in both years. In these 8 health centres the treatments dispensed for childhood diarrhoea in October of each of the years were analysed. These fully stocked health centres together treated a total of 176 and 389 cases of diarrhoea in 2016 and 2017 respectively. In 2016, before ORS/Zinc co-packs where available, 44% of cases received both ORS and Zinc even though both were in stock throughout the month. In 2017, when co-packaged ORS and Zinc was also available (as well as ORS and Zinc separately), the number of cases that received both ORS and Zinc nearly doubled to 87%. Of those that received both ORS and Zinc, 87% received them as a co-pack. It is a coincidence that both percentages are 87.
It was this analysis that led to the Zambian Government adding co-packaged ORS and Zinc to their Essential Medicines List. The Zambia experience indicates that co-packaging can increase the number of cases treated with both ORS and Zinc even in situations when both ORS and Zinc are also available separately. It goes without saying that co-packaging solves the problem of both elements of the recommended treatment being in stock at the same time.
Co-packaging also overcomes the problem of the person dispensing having to know that ORS should be given together with Zinc and removes the difficulty frontline staff face in resource-poor situations when giving two medicines to treat a single case of diarrhoea.
So, TECHNICALLY, it is true to say that it doesn’t matter if ORS and Zinc are administered from a co-pack or separately but PRACTICALLY the chance of this happening is greatly increased if ORS is co-packaged with Zinc and, in addition, the cost of treatment is likely to be lower than giving ORS and Zinc from separate sources.