Zinc/ORS Scale-up in India CHAI Diarrhea & Pneumonia Working Group June 19-20, New York
Over half of all diarrhea patients in India seek treatment from the private sector, where a majority of providers is informal Treatment – seeking for diarrhea Private providers Public providers Total: ~3.2-4M Total: ~2.8-3.3M Private provider: 55% Hospitals 5 – 8k Hospitals Mother 10 – 15k Public provider: 16% ANM RMP 1.6 – 2 million 0.6 – 0.7 million Other provider: 5% ~70% living in AWW rural villages 1.0 – 1.2 million AYUSH Home/no 0.8 – 1 million treatment: 29% ASHA MBBS Doctors 1.2 -1.4 million 80% of caregivers who seek 0.8 – 1 million treatment choose the visit a private sector provider District Level Household and Facility Survey 2007-08 2 National Family Health Survey 2009-http://www.rchiips.org/NFHS/index.shtml Department of Women and Child Development -http://delhi.gov.in/wps/wcm/connect/doit_wcd/wcd/Home/
Status of enabling elements for implementation • The RMNCH+A strategy launched in February and includes National scale-up plan Operational Guidelines (awaiting final approval by endorsed Secretary Gupta) • Schedule K status approved by Ministry of Law and out for OTC status secured for public comment (until mid-July) zinc • Need for clear consensus between MoH guidelines (which Amoxicillin as 1 st -line recommends cotrimoxazole) and IMNCI guidelines (which treatment recommend amoxicillin) • TBD Favorable policy change for amoxicillin • The Last Diarrhea Taskforce was held on May 31. Key Coordination partners include: Abt, CHAI, FHI360, HLFPPT, PATH, PSI, mechanism established UNICEF, USAID. 3
CHAI has secured large-scale funding from two donors to support scale-up over the next 3 years Madhya Pradesh Uttar Pradesh Gujarat Objective Increase uptake of zinc/ORS for child diarrhea Duration 3 years Supported By IKEA Foundation Bill & Melinda Gates Foundation Reach 50 Districts 20 Districts 26 District 30% ORS 17% ORS 36% ORS Current coverage 0% Zinc 0% Zinc 2% Zinc 50% ORS 35% ORS 50% ORS Target 50% Zinc 35% Zinc 50% Zinc 4
To increase coverage of zinc and ORS treatment in these areas, CHAI aims to shape these local markets for rural health workers and their patients IV Partnership approach, Approach Aligning activities & I leveraging existing Ensure available work/materials supply of zinc and ORS II Ensure provider Objective prescribes zinc and ORS To increase the uptake of III ORS and zinc for diarrhea Ensure caregiver treatment to 35-50% visits the provider for care Critical requirements: • Economically viable model on long term • Demand creation built on existing platforms to reach scale 5
Sustainability has been at the core of all the designed interventions 1. 2. Public Sector Private Sector • Inclusion of appropriate • Create a economically product specifications of viable supply ORS and zinc in the rate chain/distribution contracts of the state network to serve the governments and ensure rural areas consistent/timely procurement • Create a technology driven information • Introduce appropriate system to monitor and incentives for the ASHAs improve performance for using/dispensing ORS constantly and zinc as diarrhea treatment 6
In Gujarat, 3 partners have been selected for implementation and will support over 20,000 private providers 7
In MP, 7 partners have been selected for implementation and will support over 42,000 RMPs and 121,000 frontline workers Private Sector Public Sector Bioax, PSI, FHI360 MPVHA, SAMARITHAN, CID, LEPRA Society DISTRICTS DIVISION AMONG PARTNERS Madhya Pradesh Voluntary 22 Health Association (MPVHA) Bioax 9 PSI SA MA RTHA N Centre for Integrated FHI 8 BHD Development (CID) MRN GL R 11 LEPRA Society DTA SOP SVP TKM RWA CTP NMC AKN GUN SING PAN STN SDH MDS SJP VDS SAG RJG DMH UMR KTN SDL B PL RTM UJN JBP RSN S E H ANP NSP DDR IDR JBA DHR MDL DWS HSB SNI HRD CDW KND KRG BLG BRW BTL BHP
In Uttar Pradesh, 6 partners have been selected for implementation and will support over 75,000 RMPs and over 25,000 frontline workers Private Sector Public Sector Utopia, Salvo, DAZT SSS, AWARD, RGMVP 9
Partners have developed materials to support demand generation efforts 10
Diarrhea and pneumonia treatment offer perhaps the greatest untapped CHAI helped to launch the Sankalp public-private partnership, which offers a platform for securing additional contributions to the national effort opportunities to further progress towards MDG 4… Membership Goal 50+ stakeholders from government, To prevent 200,000 child civil society, academic/research diarrhea deaths by 2015 by institutions, and corporations increasing access to zinc & ORS Corporate partners Abbott McCann Health Alkem Merck AmerisourceBergen Mudra Archomei Mylan Bharti Airtel Nestle BIBCOL Novartis Cipla Ogilvy Action Dabur PepsiCo FDC Pharmasynth Guardian Lifecare Piramal GSK Synergia Haffkine Tata Consultancy Services Hindustan Unilever Teck Resources Hindustan Zinc World Courier Infosys Labs Zuventus International Zinc Association 11
The key challenge moving forward will be to bring the program to scale, particularly in UP UP District Coverage by Partner Abt Associates CHAI Saharanpur DAZT (FHI360, MI) Muzaffarnagar Bijnor UNICEF (PSI, HLFPPT) Meerut Baghpat Jyotiba World Health Partners Rao-Phule Rampur Ghaziabad Nagar BMGF Moradaba Pilibhit Bulandshahr Gautam Bareilly d Buddha Partner overlap Kheri Nagar Budaun Aligarh Shahjahanpur Shrawa St. Kansiram Nagar Bahraich sti Mahamay Mathura Kabir a Nagar Etah Sitapur Balampur Nagar Farrukhabad Siddharth Hardoi Firozaba Nagar d Manipuri Maharajganj Agra Gonda Kannauj Kushinagar Lucknow Basti Barabanki Etawah Gorakhpu Faizabad Auraiya Unnao r Kanpur Ambedkar Dehat Deoria Nagar Kanpur Sultanpur Raebarelli Nagar Jalaun Azamgarh Mau Ballia Pratapgarh Fatehpur Jaunpur Hamirpur Ghazipur Jhansi Banda Kaushambi Varanasi Mahoba Chitrakoot Allahabad Chandauli Mirzapur Lalitpur St. Sonbhadra Ravidas Nagar 12
Priorities for Q3 • Move from mapping to implementation (e.g., complete RMP mapping and begin detailing efforts) • Finalize strategy for caregiver activities • Engage with MOH of UP and Gujarat to support state activities (e.g., ASHA incentives) • Pursue funding prospects and partner commitments to help extend reach of implementation in UP • Align partners on implementation activities in UP 13
Discussion: Key lessons learned on planning and implementation 14
Thank you 15
Annex 16
With ~212,000 diarrheal U5 deaths, India represents >25% of the global diarrhea burden – with 40% of these deaths concentrated in three states Diarrhea is the second largest single cause of death in India, making it the country with the CHAI focus states in India represent ~43% of the U5 highest number of diarrheal deaths in the world diarrhea burden in the country (>90,000 deaths) Proportion contribution to cause-specific deaths among children under five year of age 2011 ~ 60,000 (28%) U5 diarrheal deaths Pneumo- nia 20% Neonatal Causes Diarrhea ~212,000 43% 13% deaths HIV/AIDS 10% Malaria 10% ~ 21,000 (10%) ~ 9,000(5%) U5 Measles U5 diarrheal diarrheal deaths 4% deaths Source: World Health Statistics 2011 www.who.int District Level Household and Facility Survey 2007-08
Rural India carries most of the child mortality burden and is where 69% of the population live % of U/5 diarrhea deaths in CHAI focus area Gujarat Rural 4% 6% 2% Urban Urban Madhya Pradesh “The rural -urban 23% difference in mortality is Rural especially large for children in the age interval 1-4years, for whom the rate in rural Rural areas is twice as high as 54% 11% the rate in urban areas” Urban Uttar Pradesh 18 National Family Health Survey (NFHS-3) 2005-06
Over the course of 3 years, we will establish an extended, economically viable, medical detailing/sales force that serves providers in rural areas Product Information NGO Partners Pharmaceutical Entrepreneurs Medical Large Associations Pharmaceutical IMA and IAP CMEs Sales-Force Sales-Force Sales-Force RMPs RMPs MBBS MBBS Educate RMPs about benefits of zinc/ORS >500K 50K-500K 5K-50K Less than 5K Provide them with stock to anchor the Pharma behavior change Distribu- 19 tion reach
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