As we come across innovations around the co-packaging of ORS and Zinc we will place details here. If you are aware of an innovation not listed here please leave the details in the comment form below and we will update this page. Comments won’t appear immediately as they are moderated.

1. 1. Product design
      1. Engaging users in product design
      2. ORS sachet size
      3. Using the packaging as a measuring device
      4. Carrying the brand on the instruction leaflet (transparent packaging required)
   2. Use of the private sector
      1. Holistic approach
      2. Multi-channel distribution
      3. Drug detailing (awareness raising/training for pharmacies & drug shops)
      4. Value chain thinking
      5. How to subsidise

1. Product design

To date, with the exception of one initiative (see below), product design has received little attention in efforts to embed the use of co-packaged ORS and Zinc. Initiatives have tended to take existing components (ORS sachets and Zinc blister packs) and place them in a newly designed cardboard box. Some concept-stage initiatives have not gone this far and simply bundled ORS sachets and blister packs by hand with no purpose-made packaging.

The exception to this is ColaLife’s work in Zambia (from 2010) where product design was the foundation of everything. As with many other ORS/Zinc initiatives, ColaLife’s initial focus was on the private sector and for private sector channels to work, there needs to be demand for the product – ColaLife saw product design as a key determinant of demand.

1.1 Engaging users in product design

ColaLife’s focus group work and findings are described and detailed here. The key issues to emerge were:

1. 1. • • the preferred product branding
        • the fact that 1 L ORS sachets are too large when treating a single child in the home
        • the challenge measuring the correct amount of water to mix the ORS correctly
        • affordability

Following the 12-month trial the product design was further modified based on feedback from caregivers gathered in household surveys. These changes are described here.

1.2 ORS sachet size

200 mL sachets of ORS

“When the one litre package was designed and promoted by WHO and UNICEF, it was intended for use essentially in health facilities. For home treatment of diarrhoea, the emphasis was put on homemade solutions. However, it is clear that more and more often ORS is being used at home and for home treatment a one litre package is clearly inadequate.
For home treatment of diarrhoea, studies have shown that the average consumption of ORS is 400ml per day for an average of two days…. And what we see in many countries is that mothers, especially in a very poor environment, who do not like to discard leftover solution, do not dissolve an entire packet of ORS in one litre of water, but just pour a little bit of powder in an undetermined amount of water, making a solution of unknown concentration, sometimes too diluted to be effective, and sometimes too concentrated to the point of aggravating diarrhoea through osmotic diarrhoea.
Realising this, WHO and UNICEF are now recommending the use of smaller ORS packets for home use (200ml ORS packets and 500 ml ORS packets), which are now being supplied by UNICEF.”

Olivier Fontaine, Dept of Maternal, Newborn, Child and Adolescent Health, WHO, Feb-2012

One litre sachets were not designed for the home treatment of diarrhoea. A caregiver treating a single child in the home, who follows the instructions, will throw away more ORS solution than is consumed by the child. Mixed ORS should be discarded after 24 hours due to the risk of contamination.

For this same reason, two ORS sachets will only provide treatment for two days.

The provision of the same amount of ORS in smaller sachets (200 mL or 500 mL) will eliminate waste, be easier to use and will provide treatment over a longer period without the risk of contamination.

Co-packaged ORS and Zinc will be used primarily for the home treatment of diarrhoea and so should ideally contain 200 mL or 500 mL sachets of ORS.

1.3 Using the packaging as a measuring device for the amount of water needed to mix the ORS

The ColaLife Operational Trial in Zambia (COTZ) in 2012/13 found that only 60% of caregivers mixed ORS correctly when given 1 L ORS sachets. This improved to 95% for caregivers using a co-pack with 200 mL ORS sachets in hard plastic packaging that could be used as a measuring device for the water.

This design feature was maintained in the modified co-pack designs used in the scale-up.

However, the measuring benefit was not seen in the scale-up. This was probably due to the fact that the intensity of the awareness raising programme was lower in the scale-up phase.

The video below shows the measuring functionality in action.

1.4 Carrying the brand on the instruction leaflet

If the packaging material chosen is transparent plastic then there is the option to carry the product brand on the instruction leaflet. The benefit of this approach is that the same packaging can be used for different brands of the co-pack by just changing the instruction leaflet. This is the approach used in Zambia to distinguish the commercial co-pack (called Kit Yamoyo) and the co-pack given out free through government health centres (GRZ ORS/Zinc Co-pack). The only difference between these products is the front of the instruction leaflet.

The disadvantage of this approach is that it involves the use of plastic. However, biodegradable plastics are becoming more available and affordable.

2. Use of the private sector

Many of the more recent ORS/Zinc initiatives (Abt Associates, CHAI and PSI/Society for Family Health) have focussed on increasing coverage through the private sector. This clearly makes sense in countries where caregivers turn to the private sector first when seeking treatment.

2.1. Holistic approach

A review of ORS/Zinc initiatives (Progress over a Decade of Zinc and ORS Scale-up, 2016) recommended a holistic approach to increasing ORS/Zinc coverage to include:

1. 1. • • Creating an enabling environment
        • Ensuring supply of co-packs
        • Increasing health provider demand
        • Increasing caregiver demand

This reflected the approach taken by CHAI in partnership with the Government of Nigeria between 2012-2017 reported here which included:

1. 1. • • policy revision and partner coordination
        • market shaping to improve availability of affordable, high-quality ORS and zinc
        • provider training and mentoring
        • caregiver demand generation

2.2. Multi-channel distribution

It proved important in the case of the scale-up work in Zambia (from 2013) to exploit all channels to market that presented themselves. There were two unexpected outcomes from doing so:

1. 1. • • In some geographical areas the national supermarket (Shoprite) acted as the wholesaler to local community-based retailers and,
        • The NGO channel, which appeared insignificant initially, increased volumes and sold more co-packs than the national supermarket in 2021.

2.3. Drug detailing (awareness raising/training for pharmacies & drug shops)

Both Abt Associates and CHAI made individual educational visits (“drug detailing”) to pharmacies and private health service providers to improve ORS and/or Zinc coverage. Between 2011 and 2015, a project run by Abt Associates and funded by USAID, increased Zinc use in the treatment of diarrhoea from 0.8% of cases to 29.2% in three states in Ghana. Between 2011 and 2016, using drug detailing and other techniques, CHAI increased ORS and Zinc coverage in selected states in India and Nigeria and nationwide in Kenya and Uganda (Black, 2019).

2.4. Value chain thinking

During 2012 and 2013, a trial run in two remote rural district in Zambia achieved ORS/Zinc coverage rates of 46% (Ramchandani R, Berry S, Berry J, et al 2022). Key success factors were the attention to product design and the simultaneous creation of the product’s value chain.

The  starting point for the creation of the value chain was the caregivers’ willingness to pay (affordability). Having established this the initiative applied the margins expected by the players along the distribution chain – the same one used for fast moving consumer goods – to arrive at a maximum ex-factory price. Direct marketing to caregivers ensured demand while a viable value chain ensured there was sufficient incentive for all those in involved in the distribution chain to engage and deliver the product to the caregivers.

2.5. How to subsidise

Affordability is crucial to success if you are seeking to increase coverage of ORS and Zinc through the sale of a ORS/Zinc co-pack through the private sector. So, it may be necessary to provide a subsidy during a trial or start-up phase before the economies of scale associated with successful scale-up kick in.

There are only two ways to apply subsidy without destroying the value chain that will be so crucial when it comes to scale-up:

1. 1. • • At the top of the value chain to reduce the ex-factory price and/or
        • Through discount vouchers given to caregivers to reduce the cost of the co-pack to caregivers

The issue of subsidies is dealt with in more detail in the ColaLife Playbook (When and where to subsidise).