Diarrhea no more: does zinc help the poor? Evidence on the effectiveness of programmatic efforts to reach poorest in delivering zinc and ORS at scale in UP and Gujarat, India.
BACKGROUND
India has the greatest burden of diarrhea in children under 5 years globally. The Diarrhea Alleviation through zinc and oral rehydration salts (ORS) Therapy program (2010-2014) sought to improve access to and utilization of zinc and ORS among children 2-59 months in Gujarat and Uttar Pradesh (UP), India, through public and private sector delivery channels. In this analysis, we present findings on program's effect in reducing child-health inequities.


METHODS
Data from cross-sectional baseline and endline surveys were used to assess disparities in key outcomes across six dimensions: socioeconomic strata, gender, caregiver education, ethnicity and geography.


RESULTS
Careseeking outside the home for children under 5 years with diarrhea did not increase significantly in UP or Gujarat across socioeconomic strata. Declines in private sector careseeking were observed in both sites along with concurrent increases in public sector careseeking. Zinc, ORS, zinc+ORS use did not increase significantly in UP across socioeconomic strata. In Gujarat, increases in zinc use (20% overall; 33% in the Quintile 5 (Q5) strata) and zinc+ORS (18% overall; 30% in the Q5 strata) were disproportionately observed in the high income strata, among members of the most advantaged caste, and among children whose mothers had ≥1 year of schooling. ORS use increased significantly across all socioeconomic strata for children in Gujarat with diarrhea (23% overall; 33% in Q5 strata) and those with dehydration + diarrhea (33% overall; 38% in Q5 strata). The magnitude of increase in ORS receipt from the public sector was nearly twice that observed in the private sector. In Gujarat, while out of pocket spending for diarrhea was significantly higher for male children, overall costs to users declined by a mean of US$ 2; largely due to significant reductions in wages lost (-US$ 0.79;P< 0.003), and transportation costs (-US$ 0.44;P< 0.00).


CONCLUSIONS
While significant improvements in diarrhea treatment were achieved in Gujarat, new strategies are needed in UP, particularly in the private sector. If national-level reductions in diarrheal disease burden are to be realized, improved understanding is needed of how to optimally increase coverage of zinc and ORS and decrease contraindicated treatments amongst the most disadvantaged across geographic areas and axes of gender, ethnicity, education and socioeconomic status.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Amnesty E
AE
LeFevre
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Diwakar
D
Mohan
Centre for Health Research and Development, Society for Applied Studies, New Delhi, India.
Sarmila
S
Mazumder
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Laura L
LL
Lamberti
Centre for Health Research and Development, Society for Applied Studies, New Delhi, India.
Sunita
S
Taneja
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Robert E
RE
Black
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Christa L
CL
Fischer-Walker
D000067576:Child Health; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003967:Diarrhea / Q000188:drug therapy*; D005440:Fluid Therapy; D054624:Health Status Disparities; D006801:Humans; D007194:India; D007223:Infant; D008297:Male; D010342:Patient Acceptance of Health Care; D011203:Poverty; D015032:Zinc / Q000627:therapeutic use*
D015032:Zinc