We describe a highly participatory approach to improve the design and distribution of a novel oral rehydration salts and zinc (ORSZ) co-pack to treat diarrhea in children aged younger than 5 years in Zambia.

Developing existing structures and experience across multiple sectors was key to the evolving intervention design, shared vision, resulting partnership, and sustainability.

Aiming from the outset to embed a successful product for private sector manufacture, we suppressed funder and project branding, testing the product and its value chain.

The process led to the successful horizontal scale-up (replication/expansion) and vertical scale-up (institutionalization) of the ORSZ co-pack.

By involving a broad, local stakeholder group, including both public and private partners, from planning through to scale-up, health care innovations can be successfully scaled up in a locally owned and sustainable manner.

This approach to scale-up, with appropriate local contextualization, could be replicated in other low- and middle-income countries to increase the coverage of novel lifesaving therapies.

We document the development and institutionalization in Zambia of a health innovation for diarrhea treatment aimed at children aged younger than 5 years: a unique oral rehydration salts and zinc (ORSZ) co-pack. Seven recommendations from the World Health Organization/ExpandNet are used retrospectively to analyze and describe the successful scale-up of this innovation from its concept stage, including in-country expansion and policy, institutional, and regulatory changes. The 7 recommendations comprise using a participatory process, tailoring to the country context, designing research to test the innovation, testing the innovation, identifying success factors, and scaling up. The scale-up of co-packaged ORSZ in Zambia is shown to be sustainable. Five years after donor funding ended in 2018, an independent, local manufacturer continues to supply the private and public sectors on a commercially viable basis. Furthermore, national coverage of ORSZ increased from less than 1% in 2012 to 34% in 2018. A key success factor was the continuous facilitation over 8 years (spanning planning, trial, evaluation, and scale-up) by a learning and steering group chaired by the Ministry of Health, open to all and focused on learning transfer and ongoing alignment with other initiatives. Other success factors included a long lead-in of inclusive initial consultation, ideation, and planning with all key stakeholders to build on and mobilize existing resources, knowledge, structures, and systems; alignment with government policy; thorough testing and radical review of the product and its value chain before scale-up, including manufacture, distribution, policy, and regulatory matters; and adoption by the government of a co-packaging strategy to ensure cases of childhood diarrhea are treated with ORSZ. With appropriate local adaptations, this approach to scale-up could be replicated in other low- and middle-income countries as a strategy to increase coverage of ORSZ and potentially other health products.

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