Opinion: 2-in-1 — how to end child deaths from diarrhea

For a lot of people living north of the Sahara, the word diarrhea evokes fairly benign memories: a “Delhi belly” travel story, a short-lived food poisoning experience, an episode of gastroenteritis or a baby’s reaction to teething.

But for millions of children across low- and middle-income countries, diarrhea can kill. And when it doesn’t, it can cause irreversible damage to a child’s physical and cognitive development and drag children into a vicious cycle of undernutrition and vulnerability to illness.

In 2020 alone, over 5 million children around the world did not make it to their fifth birthday. Nearly 1 in 10 died of diarrhea, making it the second infectious cause of death among children under 5 globally. Sub-Saharan Africa and South Asia bear the brunt of this tragic burden, with Nigeria and India contributing the largest number of deaths.

What works

The transmission pathways of diarrhea are varied — although mostly waterborne — and subject to a wide array of social and environmental determinants including the availability of clean water, hand-washing behaviors, the prevalence of open defecation, and breastfeeding practices, to mention a few. This reality underpinned the “Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea,” launched by the World Health Organization and UNICEF in 2013, which proposed a comprehensive approach to tackle the disease through a range of preventive and curative interventions.

One decade on, the results are mixed: the burden of disease has come down significantly, but the world is nowhere near on track to achieve the Sustainable Development Goal 3.2 target on ending all preventable deaths of children under 5 by 2030. It’s clear a step change is needed to accelerate progress, and one intervention stands out as having the greatest potential to bring it about: oral rehydration salts and zinc co-packs.

It is widely accepted that the combined use of oral rehydration salts, or ORS, and 10 to 14 days of zinc supplementation can reduce childhood deaths from diarrhea. ORS significantly reduces diarrhea-related deaths, while zinc supplementation reduces the duration, severity, and recurrence of diarrheal diseases in children in the two to three months following its use. The treatment is highly effective almost regardless of the cause, or pathogen, behind an episode of diarrhea.

2-in-1: How co-packaging can save lives

This combination therapy has been recommended by WHO since 2004. Nearly two decades on in 2021, a UNICEF-led analysis including data from 79 countries indicates that the combined coverage for ORS and zinc is a paltry 15%, and that at current rates of progress, it will take more than 30 years to reach an ORS and zinc coverage rate of 80%. 

One of the reasons for this is that these two essential medicines are seldom procured together as co-packs, but individually, leading health providers to procure ORS alone and Zinc as an afterthought or a "nice to have." This needs to change urgently.

The idea of co-packaging ORS and zinc isn’t new and co-packs have existed in several countries for well over a decade. The pioneering work of ColaLife in Zambia still constitutes somewhat of a shining beacon in the journey toward normalizing co-packs for diarrhea treatment: from 2011, market shaping approaches together with a human-centered design were used to make ORS and zinc co-packs the standard way of procuring this life-saving combined therapy for diarrhea diseases, but also a desirable and affordable product for families in rural Zambia.

The combined coverage of ORS and zinc increased from 1% to 47% in the intervention districts, an astonishing result. Perhaps more importantly, the trial led the government of Zambia to scale up the model and include co-packs in its national list of essential medicines.

Systematizing co-packs

The lack of progress in normalizing co-packs as the standard commodity for diarrhea treatment was the main driver behind the move by a small number of global health leaders, organizations, and activists, to set up the ORS & Zinc co-pack alliance, also known as ORSZCA, in late 2021.

The coalition was founded to advocate for the accelerated uptake of 2019 WHO recommendation that ORS and zinc should be systematically co-packaged for the treatment of diarrhea in countries with a high burden of childhood diarrhea, and to hold duty-bearers to account for this: Words are good, but action is better and massively overdue.

This is an issue where the private sector has a crucial role to play in the design, manufacturing, and supply of a desirable product with great social and health benefits, as the story has shown in Zambia and other places since then.

But only governments and global health institutions can provide the enabling environments for co-packs to thrive at scale and become the “go-to” treatment for diarrhea — because half a million lives per year hang in the balance.