Annually, over 200K Indian children die needlessly from diarrhea despite the availability of simple, highly effective and affordable treatments: zinc and oral rehydration salts (ORS). Zinc and ORS are recommended by the World Health Organization for the treatment of simple diarrhea in children, and they can prevent over 90% of diarrhea-related deaths. They also cost less than $0.50 to administer, yet under 5% of children globally use this treatment. The issue of childhood diarrhea presents both a challenge and an opportunity: if a simple, cost effective solution exists why are so many children still dying from diarrhea?
The current model of addressing childhood diarrhea in India is broken, with gaps in both demand-driven and supply-side approaches. Mothers frequently seek a treatment that will immediately stop diarrhea; they too frequently turn to antibiotics or Loperamide. Pharmacists and doctors comply with mothers’ demands even though zinc and ORS are cheaper, more effective, and safer. At the same time, pharmaceutical companies lack an incentive to produce, promote, and widely distribute ORS and zinc due to perceived low returns on investment driven by the products’ thin profit margins. How can these daunting supply and demand challenges be overcome simultaneously to reduce child mortality?
The Indian Private-Public Partnership entitled “Sankalp: No Child Should Die from Diarrhea” is aiming to do just this – it is a collective effort targeting to prevent 200,000 child diarrhea deaths in India by 2015 by increasing ORS and zinc use. This effort represents what FSG calls collective impact (CI) – when organizations from different sectors agree to solve a specific social problem using a common agenda, aligning their efforts, communicating continuously, using common measures of success, and being supported by a coordinating backbone organization. CI initiatives consist of these unique components that, when combined, offer a fundamentally different way to solve complex social problems.
Sankalp involves more than 50 partners, including financial institutions; pharmaceutical, communications and energy companies; logistics consultancies; international NGOs; local public health foundations; academic/research institutions; communities of faith and the Indian government. Each organization (for a list of all partners, see Figure 1) contributes unique assets and expertise to the effort.
Figure 1. Sankalp Partners
The Sankalp effort goes beyond typical stakeholder collaboration as all partners agree on a common agenda – solving the childhood diarrhea problem by increasing zinc and ORS use. They’ve also agreed to focus in the northern states of India where 70% of diarrheal deaths occur (Gujarat, UP, Madhya Pradesh, Maharashtra, Rajasthan, and Bihar), with spillover effects reaching other critical areas. The efforts are further concentrated in underserved rural areas rather than urban centers and go beyond traditional mass-media mechanisms to effectively target this market, working in both the private and public health systems.
The partners are further organized by aligning their activities along two dimensions: geographically and based on key activities – demand creation, product innovation, and distribution.
Geographically, an initial district-level mapping exercise illustrated the location of current partners to reduce redundancy while ensuring coverage. In any collective impact effort, this is particularly challenging as various partners must reconcile the partnership needs with their own strategies. This was one of Sankalp’s earliest successes: mapping existing efforts to optimize geographic coverage.
For demand generation, several corporations and donors are contributing to large-scale advertising campaigns to educate families and health workers about the importance of using ORS and zinc. In terms of product innovation, new formulas such as premixed ORS and alternate presentations of zinc are being developed based on consumer research. Pharmaceutical companies are improving distribution by dedicating a portion of existing sales force time to promote ORS and zinc to pediatricians so that it is recommended as a first-line treatment for diarrhea. Innovative approaches to distribution are also being explored via joint ventures between pharmaceutical and consumer goods companies that have the capacity to distribute products widely; many of these JVs are modeled after or directly expand existing private sector medicine delivery models (e.g., Unilever’s Shakti network and Novartis’ Arogya Parivar program). Additionally, the Government of India will play a critical role in driving the effort forward. To date, the government has helped to advance supply-side scale up efforts through important policy changes, such as reclassifying zinc as over-the-counter (or Schedule K status) and providing guidance to state governments on zinc/ORS scale-up.
These aligned activities are complemented by continuous communication among the partners to learn from one another and monitor progress. As the group grew in numbers, smaller task forces were created to focus on the unique challenges associated with demand, supply, and distribution. In addition to quarterly calls and face-to-face workshops, the members also interact via an “Innovation Co-creation Platform” created by Infosys and launched by the UN Secretary-General at Davos in 2013 . This interactive website aims to facilitate unprecedented collaboration by allowing partners to upload and share videos of best practices, test new ideas, challenge existing ideas and co-design solutions.
Sankalp has three primary shared measures to monitor impact: coverage of ORS and zinc, tracked via household surveys; trends in ORS and zinc prices, based on market surveys; and ultimately, child mortality from diarrheal disease. Usage of ORS and zinc among children with diarrhea will be measured through national-level household surveys every three to five years – the next is scheduled for 2014 with a 2015 data release. Additionally, the Ministry of Health has created a “National Child Health Score Card” with key child health metrics, such as zinc and ORS coverage, that uses simple red/yellow/green indicators to highlight progress by state and district.
In any successful collective impact effort, the backbone organization is crucial to sustained success. For Sankalp, the backbone activities (facilitating communications, developing shared measures, organizing working groups, engaging stakeholders, etc.) during the launch phase were shared across the MDG Health Alliance, the Clinton Health Access Initiative, and the UN Foundation. As the effort transitions to a steady state, it will be critical that backbone responsibilities are clear and funded independently to ensure that the collective effort has the resources needed to maintain momentum. The effort will also benefit greatly from the active engagement of the government to ensure strong coordination across public and private sector activities and for translating the ambition of the partnership into practical action at the state level.
By using a collective impact approach, the Sankalp effort has gone beyond a typical awareness-building public health campaign with the goal of changing patients’ health seeking behavior and physician treatment norms to ultimately impact child mortality. As Leith Greenslade of the MDG Health Alliance commented, “If all of the organizations active in the critical areas of child health – pneumonia, diarrhea, malaria, newborn health and nutrition – worked in this way we could get a lot closer to achieving the MDG target of saving around 4 million children by 2015. Donors need to really pressure the organizations they fund to work collaboratively for collective impact, particularly in the countries where child deaths are concentrated. We have Sankalp in India, but we also need it in Nigeria, DRC, Pakistan and Ethiopia.” If Sankalp can continue to mobilize key partners and measure its successes, it can hopefully serve as a collective impact model for other organizations tackling MDGs.
By Laura Herman, FSG Managing Director and Melissa Scott, FSG Consultant
(Laura leads FSG’s global health practice area and has over 15 years’ experience advising corporations, foundations, and international nonprofit organizations on strategy development, program design, evaluation, market analyses, and organizational alignment. Melissa has worked on several global development projects, including spending one year in FSG’s India office, working with a global pharmaceutical company to increase access to diabetes treatment.)