Enablers & Barriers to increased ORS/Zinc coverage

On 15-Jul-2022 ORSZCA ran an Enablers & Barriers Roundtable.

These are the key points made in the recorded discussion and chat, broadly in the order of speaker intervention.

A very much more detailed table of the enablers and barriers including the research done before the roundtable is available as a Google Doc here. This table is modified from time to time as new evidence emerges.

John Bosco Asiimwe

  • CHWs are key to increasing ORS/Zinc coverage.
  • Distribution of ORS and Zinc prior to illness significantly increased ORS/Zinc use (see paper with David Lavine).
    Note that India also included co-packaged ORS and Zinc in the Intensified Diarrhoea Control Fortnight (IDCF) 2019 Guidelines but left it to the discretion of states if they want to use it in their state. During the IDCF treatments are also issued prior to illness.
  • In 2021 there was 45% availability of ORS/Zinc.
  • Quality and Equity are two areas getting attention that need to be addressed – see just-published WHO proposed Pediatric QoC core indicators which explicitly reference treatment with ORS/Zn.
  • How can we better leverage the focus on “zero-dose” kids in immunisation to make sure we are getting to the kids most likely to die from diarrhoea?

David Levine

Leith Greenslade
Special Advisor, ORSZCA

Atanur Arapoglu

  • International supply chains are a challenge for iNGOs like Maternova and for UNICEF
  • Landlocked countries, such as Uganda, are particularly problematic.
  • Limited registered suppliers locally is a great challenge; finding dedicated international distributors willing to guide and partner with equally dedicated local suppliers is rare.

Zulfiqar Bhutta
University of Toronto and Aga Khan University

  • Many countries are producing ORS and Zinc products locally and so then international supply chains are less of an issue.
  • However,  the issues are more than the supply chain only – many of the barriers and lessons from our Pakistan study a decade ago are still relevant. See https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/1471-2458-13-922.pdf
  • More could be done by, and through, the private sector to scale-up ORS/Zinc coverage.
  • No research has been done into the effect of Zinc in infants under the age of 6 months, yet we have set ourselves the target of 90% coverage in this age group which may not be necessary.
  • The messaging around co-packs is challenging as they contain two items (ORS and Zinc) with different regimes. No one gives ORS beyond the duration of the diarrhoea episode but it is currently recommended that Zinc is given for 10-14 days. Very few mothers are going to do this. And is it really necessary?
  • Is there a place for a co-pack with only 3 or 4 Zinc tablets? More research is needed to measure the effect of Zinc when given for fewer days.
  • Zinc deficiency at population level has changed (eg reduced by 50% in Pakistan).

Yewedalem (Yodi) Tesfaye
Results for Development

  • ORS/Zinc is now part of the national logistic management information system used by Health Centres to restock; this creates a pull effect.
  • Sustainable financing is an issue; donor support is decreasing and the burden comes to government financial commitment.
  • Government treasury investment increases could help, but this requires advocacy and communication to key stakeholders/top management.
  • Private sector advocacy, plus media coverage and availability of Zn-ORS as OTC has improved the population awareness co-pack benefits.
  • Collaborative working (CHAI, USAID grantees, R4D, others) and a Technical Working Group strengthened the NCH (Neonatal & Child Health) supply chain management.
  • Challenges include hard currency issues, increase in prices (x3), raw material import and limited supplier numbers.

Alison Greig
Nutrition International

  • Nutrition International currently supports the governments of Ethiopia, Kenya, Nigeria, Senegal, Pakistan and Bangladesh with diarrhoea management, including ORS and Zinc.
  • NI is supporting a few states of Nigeria to include Zinc/ORS copacks in their drug revolving funds in an effort to improve sustainable supply to health centres..

Malia Boggs

  • Welcome the work of ORSZCA in advocating for co-packaged ORS and Zinc in the context of diarrhoea case management.
  • Advocacy is needed as there is waning momentum among the key players (national and international) in this area.
  • We need to focus our efforts in countries/areas that are falling behind.
  • USAID/SHOPS/CHAI event (Dec 2020) summarised lessons learned in the previous 18 years: support from government; supply and demand issues The USAID/SHOPS/CHAI slides are here: USAID Partners’ Meeting_Building on Over a Decade of Progress in ORS_Zinc. [Ed: the ORSZCA Enablers & Barriers table, which was built on during the roundtable is structured in a similar way, building on the recommendations in the publication: Progress over a Decade of ORS and Zinc Scale-up – best practices and lessons learnt (2016)].
  • Partnerships have been critical, with international and local pharma companies to address gaps in supply and to ensure high-quality products are available.
  • Comprehensive programs really need to encompass policy, supply and demand (caregiver and provider).
  • A secondary analysis on adherence to IMCI in 7 countries has revealed very poor quality of care, especially related to managing diarrhea.
  • Collecting high-quality data is also essential: using data to better target “zero dose” and vulnerable children.

Patricia Jodrey

Felix Lam
Clinton Health Access Initiative (CHAI)

  • CHAI ran ORS/Zinc programmes in Nigeria, Uganda, India and Kenya from 2011 to 2016. Coverage for ORS/Zinc increased from 1% to 24% during that period.


  • More recent DHS surveys in those program countries show ORS/Zinc coverage has maintained or slightly increased after the programming ended – demonstrating that the implementation model is sustainable
  • However, there is a risk that coverage can reverse (as seen in Tanzania with ORS) so ongoing work may be needed to sustain behaviour change, just like any public health campaign (e.g. vaccines, anti-smoking, etc.).
  • Highlighted the effectiveness of the various tactics which were adapted to country context such as:
    • Distribution of ORS and Zinc prior to illness during the Intensified Diarrhoea Control Fortnight (IDCF) in India. The IDCF takes place just before the peak of the diarrhoea ‘season’ in India.
    • Co-packaging ORS and zinc to reduce the cost of the total treatment and increase access
    • Demand generation through influential community leaders, such as women’s self-help groups in India, preachers and Islamiya schools in NIgeria, drug shop associations in Uganda
    • Supply co-ordination so that ORS/zinc is already on the shelves at the same time as community demand stimulation is important.
  • More large-scale programming (funding), adapted to the country context, is required.

Banda Ndiaye,
Deputy Regional Director, Africa Nutrition International

  • Community Health Volunteers are crucial for increased ORS/Zinc coverage but these tend to be only effective when associated with ‘projects’ that give them access to co-packs.
  • Strengthening and supporting the ‘community platform’ is crucial to increasing ORS/Zinc coverage.

Johnson Olusetire
MD, Olpharm Nigeria (Manufacturer)

    • Awareness of ORS/Zinc dropped after withdrawal of CHAI/SHOPS/IKEA projects.
    • Co-packs are available in Nigeria but there is a lack of awareness and demand.
    • Doctors are not prescribing ORS and Zinc.
    • Currently NI and the Society for Family Health (PSI affiliate) are distributing to states where they have projects but there is no institutionalisation.
  • We need more sensitisation, community awareness and detailing with pharmacies.
  • There is confusion as to what a co-pack should contain: some projects require 2 sachets of ORS and some require 3. There needs to be uniformity [for manufacturers]. 

Priyamadhaba Behera
All India Institute of Medical Sciences (AIIMS)

  • Up until 2018, co-packaging was not permitted.
  • What co-pack do they use for the Intensified Diarrhoea Control Fortnight (IDCF)? [As no diarrhoea co-packs are available in India].
  • ORS/Zinc co-packs would increase Zinc coverage.
  • Compliance of doctors may be poor in the management of diarrhea. See the study of Eastern India – https://pubmed.ncbi.nlm.nih.gov/33763320/

Al Murugappan
Pharmanova (Manufacturer)

  • There is a high awareness and enthusiasm for co-packs.
  • Awareness among caregivers is there.
  • The key barrier is budgetary constraints experienced by the government.
  • Pharmanova sells more litre sachets of ORS to the government than co-packs [Ed: Co-packs are not expected to replace ORS-only as they are primarily for the home treatment of diarrhoea in children.]

Jane Berry

Simon Berry

Joseph Monehin
Co-chair of the Commodities Sub-group of the Child Health Taskforce

  • It was a missed opportunity not to  introduce the co-pack when the recommended treatment of diarrhoea was changed to ORS and Zinc in 2004.
  • USAID/SHOPS/CHAI have done a lot of good work in recent decades on the supply side of the ORS/Zinc coverage issue.
  • However, we have not promoted Zinc in the same way that we promoted ORS in the early days to make it a ‘household name’.
  • Multiple strategies are now needed, including social marketing, to stimulate demand for Zinc.

Eric Van Genderen
International Zinc Association (IZA)

    • The IZA has access to mineral extractors around the world.

Mirafe Solomon
Save the Children

  • The Ethiopian Pharmaceuticals Supply Agency (EPSA) is the organisation responsible for (public sector) medicines distribution.
  • Co-packs are manufactured locally but sometimes there are shortages and these need to be procured from the international market.
  • There is good demand for ORS but not for the co-pack.

Hope Randall
PATH/Defeat DD

  • Why not have co-pack distribution alongside rotavirus vaccination?

Samy Ahmar
Save the children

  • While seeking to increase ORS/Zinc co-pack coverage is a narrow focus, it is nonetheless high impact/high return, and does not necessarily require high investment.


SB/JB 25-Jul-2022




Making co-packaged ORS and Zinc the "go to" treatment for childhood diarrhoea