Table 1 Diarrhea Alleviation through Zinc and Oral Rehydration Therapy (DAZT) Program Summary

State-level policy changes

• Permission to implement DAZT was formalized through Memorandums of Cooperation between MI and the state government, and MI and the Department of Health and Family Welfare of Gujarat

• In Uttar Pradesh, less formal permission was obtained from the government

• Commitment from the Department of Women and Child Development in Gujarat

• Both states added zinc to their NRHM guidelines and essential drug lists

Programmatic planning

National Rural Health Mission (NRHM) Program Implementation Plans (PIPs) were changed to include the procurement of zinc and ORS

Training

Three levels of training were conducted including (1) district level supervisors, (2) Block level supervisors and health workers, and (3) ASHAs and AWWs. Trios, a Delhi-based agency, conducted training in Gujarat, and three NGOs conducted the training in UP

Supply

• Supply was provided by two pharmaceutical companies including Healthy Life Pharma and FDC limited assuming that the public sector would treat 10% to 15% of diarrhea cases

• Kits contained two ORS sachets and 14 taste masked zinc tablets, a measuring cup, and an informational leaflet for caregivers

Procurement

• Healthy Life Pharma and FDC limited provided the first procurement of kits

• In Gujarat, in phase 1 (2011), MI provided ORS and zinc and in phase 2 (2012), MI limited its provision to zinc only (government procured ORS)

• In 2013, the state governments disbursed funds to all districts to purchase zinc

• ANMs may have used supply procured from sources other than MI

Incentives

Incentives were delivered to ASHAs, AWWs, and ANMs at monthly meetings to increase attendance rates

Distribution

• Supplies were distributed from Healthy Life Pharma to district medical stores, to district hospitals or block offices/CHC/PHC, to HSC-ANMs and CDPOs, to ASHAs and AWWs

• ANMs informed PHC block level supervisors about needs; supplies were redistributed from areas of surplus to areas of shortage

Monitoring and supervision

• Supportive supervisors and MI divisional coordinators provided supportive supervision at the district, block, sub-center, and village levels in the form of data validation and capacity building

• These mechanisms complemented existing monitoring mechanisms of the public health system

• Supervisors attended monthly meetings of ASHAs, AWWs, ANMs, spent at least 18 days monitoring field staff visits, provided staff with hands on training when necessary, analyzed service provider knowledge and skills, stock status, and caregiver compliance with treatment

Private sector

Family Health International-360 (FHI-360)

Policy changes

• Memorandums of understanding were signed with prominent professional medical organizations (IAP, IMA, and other local medical associations)

• Partnered with NGOs, pharmaceutical companies, and homeopathic and alternative medicine associations

Programmatic planning

An implementation plan was developed which involved a push and pull strategy—push: changed prescription among key opinion leaders in the medical community and created IEC materials with medical experts about diarrhea management and marketed ORS and zinc to RMPs and drug sellers; pull: natural demand creation for ORS and zinc within this group

Training

• NGO and pharmaceutical staff trained for three days in diarrhea epidemiology, importance of zinc and ORS, correct dosage and regulatory guidelines, and promotional strategies for effective product placement

• Professional organization were provided with continuing medical education

• DAZT corner staff were trained on selected topics from the three day training schedule

• In UP, ten RMPs from the Sehat Mitra project were trained with an adapted version of the three day training session

Supply

Local manufacturers were linked with informal providers in designated areas

Procurement

Utopia Pharmaceuticals and Prayas manufactured and distributed zinc in UP, and RMPs procured zinc from West Coast Pharmaceuticals and generic brands from NGOs in Gujarat, with procurement plans accounting for different levels of demand according to season

Incentives

Pharma companies provided field representatives with commissions of 2 Rupees for each sale above 200

Distribution

Generic distributors supplied District Coordinator offices, which distributed to the Tehsil Coordinator based on demand

DAZT corners

Staffed informational booths in private clinics and hospitals to create awareness among caregivers and remind providers to prescribe zinc

Sehat Mitra project

In Faizabad Uttar Pradesh, a pilot project to provide ORS and zinc in patient’s homes by RMPs traveling on bicycles

Monitoring and supervision

• Monthly NGO and pharma staff meetings, validation of data and reports, SMS messaging from the field

• FHI staff attended monthly meetings, district coordinators spent a lot of time in the field working with new staff