An evaluation of a national oral rehydration solution and zinc scale-up program in Kenya between 2011 and 2016.

BACKGROUND: In Kenya, diarrheal disease is the second leading cause of death among children under five. The Government of Kenya launched a national plan to increase coverage of oral rehydration solution (ORS) and zinc by addressing demand and supply-side barriers. This study evaluates progress of ORS and zinc uptake in Kenya according to the national plan from 2011 to 2016. METHODS: In 2016, we conducted a nationally representative population-based household survey to estimate coverage of ORS and zinc for treatment of diarrhea cases among children under five. We also used ORS and zinc coverage data from the two most recent Kenya Demographic and Health Surveys in 2008/09 and 2014 to estimate annual changes in coverage rates during the program period. Based on these inputs, we used the Lives Saved Tool to estimate the number of diarrhea deaths averted between 2011 and 2016 due to increased use of ORS and zinc. RESULTS: The 2016 survey results showed that ORS coverage was 42% (95% confidence interval (CI) = 38%, 47%) and zinc coverage was 18% (95% CI = 15%, 23%). The estimated coverage for the combined use of ORS and zinc was 15% in 2016 (95% CI = 12%, 19%). Compared to 2011, an additional 3340 (sensitivity bounds = 2 670, 3 920) diarrhea deaths among children under five were averted due to increases in ORS and zinc coverage. CONCLUSIONS: Kenya was successful in catalyzing uptake of combined treatment with ORS and zinc, which rose from 0.8% in 2011 to 15% in 2016. Ongoing efforts are necessary to further build on these gains.

Increasing coverage of pediatric diarrhea treatment in high-burden countries.

BACKGROUND: Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. METHODS: We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. RESULTS: Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21-23%) to 48% (95% CI = 47-50%) and program states in Nigeria, from 38% (95% CI = 32-40%) to 55% (95% CI = 51-58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. CONCLUSIONS: Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.