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Opinion7th January 2013

How do you solve a problem like diarrhoea?

The Zambian sun is burning fiercely in the bright blue sky. Mothers and children, queuing at a clinic on the outskirts of Lusaka, receive little relief from the thatched gazebos meant to protect them from the heat. Many have walked long distances to be here, carrying babies on their backs and holding small children tightly by the hand. They came at dawn, hoping to be seen quickly but prepared to wait patiently for their turn. The women chatter quietly among themselves. Children play in the dust. Nurses and clinic staff bustle about their business, pausing occasionally to greet waiting patients.

The scene at this clinic paints a picture of Zambia’s overstretched public health system. This is a system that might battle valiantly but cannot prevent the deaths of more than ten percent of children before their fifth birthday. What might be surprising is that one of the biggest killers of children is diarrhoea: a disease so preventable, so treatable that in western society it is barely considered a disease. But in Africa diarrhoea is the second leading cause of death of children under five. Diarrhoea and pneumonia together kill more children than AIDS, malaria and measles combined. And yet they attract less than five percent of global health funding.

In Zambia diarrhoea claims the lives of 45 children every day. How do you explain a preventable, treatable disease that kills 15,000 kids each year? A nurse at the clinic provides me with a simple answer: diarrhoea is just a nuisance. A mother does not perceive it as a deadly threat to her child. So she will tend to treat the symptoms at home with drugs, often the wrong ones, bought at a local village kiosk, and will only seek help at the clinic when the child is very ill: limp and lethargic from dehydration.

Affordable and effective medicines – oral rehydration salts (ORS) and zinc – exist to treat diarrhoea. Yet these very basic technologies remain elusive to the mothers waiting at the clinic. Private vendors often prescribe the wrong treatment – antibiotics rather than the cheaper and effective ORS and zinc. Or, like today, women walk with their sick children to the health centre and wait for hours only to find that the clinic pharmacy is out of stock. The private sector – often that small village kiosk – is the first stop for many Zambian mothers when their child is sick. Yet the supply of these life-saving medicines is inconsistent, vendor knowledge is poor and consumer demand is low. Put simply, customers are not asking for ORS and zinc so the market does not sell it.

Ark challenged the Business Innovation Facility (BIF) to help find a push and pull market solution. Specifically, how do you create demand for and supply of diarrhoea medicine? How do you make sure that children are treated quickly and correctly, before they become so ill they may face long-lasting effects? The team from Ark and BIF analysed the supply chain from manufacturer, through distributor, wholesaler and dispenser all the way to the point of purchase and use by the consumer. We assessed the barriers at each point and considered opportunities for market leverage. We spoke to mothers, to nurses and to private medicine vendors to find out why zinc has just two percent coverage across much of the country and why antibiotics are often given in place of ORS.

We were encouraged to find entrepreneurs acting innovatively and creatively: ColaLife , for example, is using Coca Cola’s distribution channels to carry life-saving medicines to remote communities. Our prior assumptions were challenged with wisdom and insight from Zambia’s Board of Traditional Practitioners. And we heard strong support from the Ministry of Health for working with the private sector – an approach soon to be enshrined in law through its public-private partnership for health legislation.

Applying simple business principles to ORS and zinc makes it a tough sell: these are cheap products; with low potential margins; and even the most talented of marketing gurus would struggle to make diarrhoea medicine aspirational. But the potential market is immense, and there is space for disruptive innovation. And while humble kiosks in rural villages may not look like prime commercial opportunities, they tend to be centrally located, enjoy market domination and consumer confidence and could make great distribution hubs.

We are but one small actor in this ecosystem and there is certainly no single solution to a complex problem like diarrhoea. But those mothers, waiting to see a doctor under the hot Zambian sun, want, deserve and have the right to better health for their children. Our role is to find innovative and long lasting ways to make this happen.