Millions Saved - Case 7: Preventing Diarrheal Deaths in Egypt

This chapter from the book Millions Saved details the diarrheal control programme implemented in Egypt during the 1970s and 1980s. In 1977, diarrheal diseases, which result in life-threatening dehydration, were identified as a major cause of infant deaths in Egypt. This finding led to the establishment of the National Control of Diarrheal Disease Project (NCDDP) of Egypt to promote the use of locally manufactured oral rehydration salts, which reverse the course of dehydration. The programme's goal was to distribute the salts, along with information about the appropriate treatment of children with diarrhea, through public and private channels, including mass media avenues such as television. The four main components of the programme included product design and branding, production and distribution, training, and promotion and marketing. This summary will focus on the promotion and marketing report contained in the cited article. It is not an evaluation of a specific programme as such but merely a historical overview of the national campaign.

Background

Diarrhea was responsible for more than 30% of all hospital admissions of children, and many people had adopted the practice of administering popular drugs, such as antibiotics, which can stop diarrhea but still expose the child to the risk of de-hydration. The majority of these drugs demonstrate no proven health benefit and in some cases cause dangerous side effects. Part of the NCDDP plan was to change this practice and to introduce ORT into wider circulation. To meet this objective, the national programme had to change the behaviour of mothers and physicians and ensure an adequate supply of ORS. While packets of table salt, baking soda, and glucose could be prepared for one penny per liter of fluid, mothers still needed to understand the value and proper use of ORT, and physicians needed to be convinced of its efficacy over competing treatments such as intravenous therapy, drugs, and fasting.

Strategies

A key component of the programme was the social marketing and mass media campaign. The primary audience for the outreach was mothers of children under 3, health professionals, pharmacists, and media reporters. In 1984, the first national media campaign was launched, concentrating of the dangers of diarrhea, explaining its causes and the means to reduce its impact and severity. The programme's launch was aided by the rapid and exponential increase in the share of Egyptian households that had televisions. The percentage with a television had skyrocketed from 38% in 1980 to 90% in 1984. Television became the primary media outlet of the campaign and provided a powerful vehicle to spread the programme’s core messages and to reach even rural, illiterate households that would have been inaccessible through print media. More than 63 television spots were aired between 1984 and 1990, and billboards, magazine ads, and posters were used to supplement the television messages. The language was simple, employing expressions commonly used by mothers, with a theme of maternal love.

Impacts

The mass media campaign was found to be exceptionally effective and the article suggests that it was a resounding success. After the first national campaign in 1984, more than 90% of the mothers knew of ORS, and ORS use increased to 60%. In 1991, when the 10-year programme ended, virtually all of the goals had been reached. By in 1985 and 1986, at the midpoint in the programme, the distribution of ORS was four times the level at the start of the programme. By 1986, nearly 99%of mothers were aware of ORS, use of the solution was common, and a majority of women could correctly mix the solution. In addition, the number of children with diarrhea attending a public clinic rose from 630,000 in 1983 to 1.4 million in 1985, another indicator of learning and knowledge with regards to diarrhea. Overall infant mortality dropped by 36 % and child mortality by 43% between 1982 and 1987. Specific mortality caused by diarrhea also declined during this same period, from 82% among infants and 62% among children. It is estimated that the national campaign helped to avert 300,000 childhood deaths between 1982 and 1989. Despite these improvements and widespread adoption of the therapy, it was found that the private sector was still largely resistant to conversion to ORT, in part because of the greater economic returns generated by anti-diarrheals.

The chapter also looks at the cost-effectiveness of the intervention, and the chapter provides evidence that the average cost per child treated in Egypt with ORT was less than $6 and the programme calculated that the cost per death averted was roughly between $100 and $200. The total programme cost was $43 million: $26 million in grants from USAID and $17 million in cash and in kind from the government of Egypt.

Conclusions

The authors suggest that there are two elements of success that are worthy of specific identification. First was the use of scientific investigation, including research that supported various parts of the programme and the evaluation efforts; and second, the programme's flexibility. The programming and marketing was supported by substantial amount of anthropological and epidemiological research, and the widespread involvement of most Egyptian universities and medical schools in the effort spread the message to the medical community. In addition, an evaluation component was present from the outset of the programme, and this allowed for corrective interventions during the life of the programme. The diarrheal programme was also flexible in that it used and responded to trial and error and feedback from evaluation evidence. Interventions were tested in episode pilots and rehearsals and different elements of the programme were constantly adapted. The authors conclude that these features made and important contribution to the success of this national campaign.