Stop Diarrhoea Initiative India – what have we achieved? What have we learned?

Hours, weeks, months, gathered together in an office, scribbling on flipcharts, sharing ideas, reading through primary and secondary data, endless emails, a plethora of post-it notes to develop the theory of change…   Until finally, the Stop Diarrhoea Initiative (SDI) design was born – a four-year programme, funded by Rickett Benckiser (RB) in partnership with the Government of India, targeting a reduction in cases of diarrhoea in four states in India, Delhi, Uttar Pradesh, Uttarakhand and Kolkata.

That was in 2014. Back then, it felt impossible to visualise four years ahead and imagine our final dissemination meeting in 2019. But two weeks ago – on 15 March – it happened. We found ourselves clustered together in a much larger room in central Delhi, crammed with specialists in child health, nutrition and sanitation in India, together with our partners and beneficiaries who we collaborated with tirelessly during the programme cycle. Together we all sat gazing at colourful slide decks summing up our efforts.

“That’s it,” says a voice in my head, as I recall the journey we’ve been on. Four years squeezed into a PowerPoint. It seems a disservice but, hey, I guess that’s the point of a project dissemination and learning workshop.

From those early days in 2014, SDI has grown into an intersectoral, robust adult of a programme with a far-reaching presence across the four implementing states. From that initial design workshop, SDI India has evolved into:

  • testing an evidence-based strategy;
  • experimenting with a series of programme models; and
  • showcasing the importance of community led development as a core framework to achieve not only our programme outcomes but solutions for India’s Swachh Barat Mission and rural health mission to tackle diarrhoea.
Rekha and Rishabh at a Save the Children mobile health unit in Delhi, where they have come for a check-up. Rekha had a daughter Tannu, who died at the age of four from diarrhoea and other complications. (photo: CJ Clarke/Save the Children)

It’s been a highly challenging programme, at times arduous to deliver. But dedicated teams have developed positive working relationships with government, lobbying, campaigning and advocating for strong community structures and polices that prevent children dying from diarrhoea and pneumonia.

SDI has contributed to Save the Children’s global ambition to reduce diarrhoea as one of the leading causes of death among children by 2020. Diarrhoea is the third leading cause of death in children under five, with an estimated 1.7 billion cases of cases per year, resulting in 480,000 child deaths. Even more startling, 60% of diarrhoea-related deaths are caused by the contamination of water or food – a result of poor sanitation and inadequate hygiene practices. The two countries with the greatest burden of diarrhoeal disease are Nigeria and India. In both countries SDI has focused on a multifaceted set of interventions.

In India, 102,000 children’s deaths a year – 280 child deaths every day – are attributed to diarrhoeal disease. With that level of burden, it was important to deliver a comprehensive, multi-thematic multi-sectoral programme that would implement cost-effective, high-impact interventions to win the fight on reducing mortality at scale. This approach was at the core of SDI’s aims to increase:

  1. access to quality diarrhoea prevention and treatment services for at least 80% of households in target intervention areas in target locations by the end of the programme
  2. community awareness, knowledge and practices of prevention and control of diarrhoea in target areas improved by 80% by the end of the programme
  3. national, State and community accountability and ownership for increased access to diarrhoea prevention and control and scaled up at all levels, enhanced by the end of the programme.

The programme framework was based on implementing a package of seven evidence-based prevention and treatment interventions to control and prevent diarrhoea, known as the 7-Point Plan for Diarrhoea Control. This combination, recommended by the World Health Organization (WHO) and UNICEF, was the precursor to the WHO Global Action Plan for Pneumonia and Diarrhoea, which includes all seven recommended interventions, together with those specific to pneumonia. To sustainably tackle diarrhoea, which is a public health burden, the WHO and UNICEF plan is focused on providing adequate coverage of interventions necessary to eradicate diarrhoea.

The plan comprises:

  • a treatment package
    • fluid replacement (oral rehydration salts [ORS]) to prevent dehydration
    • zinc supplementation
  • a prevention package
    • rotavirus and measles vaccinations
    • promotion of early and exclusive breast feeding
    • vitamin A supplementation
    • promotion of handwashing with soap
    • improved quantity and quality of water, and community wide sanitation promotion.

SDI works to increase access to water and sanitation services in schools and communities, along with immunisation coverage and health services. It’s supported by a social behaviour change and communication strategy to increase knowledge and community cohesion. Moreover, it seeks to increase support, sustain services and behaviour change, and improve and manage services, while advocating for sufficient budget and requisite policy changes.

Achievements

We have:

  • achieved an estimated reduction of 62% diarrhea prevalence in SDI intervention areas, compared with 41% in control areas, preventing an estimated 16,286 child deaths cases (based on an estimate of diarrhoea being fatal in 15% of cases)
  • achieved over 80% coverage in exclusive breastfeeding water and sanitation and handwashing after defecation within the four states
  • achieved our target for measles coverage and rotavirus has started in two states
  • increased treatment with ORS and zinc combined from 9% to 22%
  • increased knowledge and health-seeking behaviour in our communities to over 80%; and our approach to social behaviour change and achieving open-defecation-free status in our communities has been recognised by the government in all four states.

Our community interventions have started to be adopted. We will work though a series of stakeholder meetings to increase this commitment to date before the end of the programme.

With collaboration between health, WASH (water, sanitation and hygiene) and nutrition sectors at its core and an integrated model of prevention and treatment, SDI has gained real traction through an integrated implementation model for diarrhoea control and prevention. SDI developed local ownership for improving child-health-related services amongst community members – for example, children were supported to be agents of change able to advocate for improvements in WASH in their communities and other health-related issues through the creation of child health and hygiene clubs. Other community-based interventions included:

  • a community scorecard tool
  • a non-emergency helpline to counsel caregivers of children with suspected diarrhoea and a referral mechanism
  • mother-to-mother support groups for health promotion.

A digital training tool for frontline health workers has enabled better data capture and targeted messaging accuracy. Advocacy for combined packaging of zinc and ORS, and medication demonstration corners in health facilities and key meetings have achieved greater treatment adherence. The programme has also trained a cadre of health workers for health promotion that has been recognised and adopted by the government.

As SDI draws to a close, it leaves a legacy of a strong results framework and high-impact interventions that have been adopted by district, state and national level stakeholders in some programme areas. Relatively low-cost, game-changing interventions – such as co-packaging ORS and zinc, and upskilling frontline health workers in diarrhoea control and prevention – have generated enough evidence of their impact to grab the attention of high-level decision-makers and policy-makers. Further work is required, however, to advocate for the states to adopt the full SDI package of interventions.

These high-level wins demonstrate what the SDI programme has accomplished in some programme areas. But much more work is needed to ensure our ambitions of equitable across all states of India to such life-savings interventions are achieved. So that the poorest and most marginalised children – who are at the core of Save the Children’s work globally – will no longer be ignored.

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