Mothers in Kenya feed oral rehydration solution (ORS) to children dehydrated from diarrhea. Photo: PATH/Tony Karumba.

ORS + zinc is the globally recommended treatment for diarrhea. Thanks to the effort of PATH and other partners of the Diarrhea Innovations Group, the World Health Organization added co-packaged ORS and zinc to its Essential Medicines List for Children in July 2019. The next step for advocates is to call for the harmonization of national lists with the updated global policy.

Through John Phiri and Irene Mirembe, who own pharmacies in Zambia and Uganda, respectively, we hear about common barriers to accessing ORS and zinc together, as well as the everyday concerns of parents whose children are sick with diarrhea. The ORS + zinc co-pack has the potential to remove some of these barriers, including cost, awareness (especially about zinc), and access.

Where is your pharmacy? What are common health concerns for children, and how does diarrhea figure in?

John: I have a pharmacy in Chilenje, Lusaka, Zambia in an urban area. The outlet serves over 100 patients daily. The most common health concerns for children in my area are colds, flu and Pyrexia of unknown origin, but we do still see children with diarrhea.

Irene: Currently, I run three retail pharmacy outlets located in semi-urban areas of Wakiso District of Central Uganda. Collectively, we serve an average of 200 clients per day, mostly from the local communities. Most of the cases we receive for children are malnutrition, diarrhea, malaria, cough and flu, respiratory tract infections, and other ailments like burns and wounds. On average we receive around five cases of diarrhea per day at all outlets combined.

When parents come to the pharmacy to treat diarrhea in the children, what are they looking for? What is their level of knowledge about diarrhea prevention and treatment?  

John: Parents with children who have diarrhea normally come to look for antibiotics or soothing powders, especially for children who are teething. A few will ask for ORS and very few will ask for ORS plus zinc. This to me shows how much of a gap there is in knowledge in the management of diarrhea.

Irene: When parents come for diarrhea treatment, most of them want a fast-acting medication for the condition. Most of them are aware that they need to take quick action once they notice it, and they often report for medication after they have noticed one or two episodes.

What are user perceptions around ORS and zinc for diarrhea treatment? Is the use of both known, accepted, and popular?  Do any parents ask for both ORS and zinc?

Irene: Some parents purchase ORS because they are aware that it is the first-line treatment for diarrhea, thanks to this information being taught to their children in school. But few of them go ahead to actually administer the ORS appropriately.

Most parents/caregivers request drugs or antiseptic solutions. Zinc is not well known and is only purchased with a prescription or after the parent/caregiver has been educated by the pharmacist.

ORS is packed in both flavored and non-flavored sachets, though customers dislike both tastes and many children vomit it when it is given. The taste of ORS also prevents many parents from giving it to the children.

Zinc comes in a solution form and a dispersible tablet. The solution is less frequently purchased because of its higher cost.

John: Most parents won’t ask for both ORS and zinc. I suggest a combination when caregivers ask about diarrhea management, but paying for both is a common factor that stops people. I once had a mother who came to the pharmacy asking for ORS because the child had diarrhea. When I suggested she gets both ORS and zinc, she refused because she needed to ration the money she had. She had to get food for the baby and also the ORS.

The use of both is acceptable if it is explained well so that caregivers don't feel like they are being exploited. Most caregivers will demand antibiotics, and it is the duty of the pharmacist to fully explain the importance of ORS and zinc as opposed to antibiotics especially in the event of diarrhea.

What are your customers’ common questions or concerns when it comes to diarrhea treatment?

Irene: Customers usually want medication that will stop the diarrhea immediately. Others mind a lot about the cost of the treatment.

John: The common concern when it comes to treatment of diarrhea is mainly the time frame to expect a response. Most parents want to know when the diarrhea will stop. And what can speed up the process.

Are there any issues with supply of either or both?

John: ORS and zinc are imported by different suppliers, so it is hard to sync the procurement and distribution of the commodities. ORS suppliers may bring ORS into the country, but then you may find zinc is out of stock. Kit Yamoyo (co-pack) is not sufficient on the market to warrant adequate flow in the distribution chain.

Irene: For the ten years I have spent in pharmacy business, I’ve hardly had issues with the supply of ORS. However, we have had challenges with zinc. A few years ago, it was off the market for some time.

How are ORS and zinc sold at your pharmacy – as separate products, a co-pack, both?

John: We have both ORS and zinc as separate entities and the co-pack (Kit Yamoyo). We sell in accordance with what the caregiver is able to manage but we emphasize the co-pack. The average retail selling price for zinc is around $0.85 and for ORS ranges from $0.15 to $0.41. The co-pack retail prices averages at around $1 and includes ORS, zinc, and hand soap.

Irene: ORS and zinc are sold separately at the pharmacies. Co-packs exist although they are rare in the private sector.

Zinc is quite costly and the community has not been well educated about the benefits of zinc after diarrhea. The introduction of the co-pack will enable the community to appreciate the benefits of zinc. If not too costly, I believe customers will embrace it.

As more pharmacies and communities become aware of the co-pack, and as more manufacturers contribute co-pack products to the market, we expect to see a more stable supply, uptake, and knowledge about this cornerstone diarrhea treatment among the communities whose children need it most. Learn more.