The final keynote presentation at the IHI/BMJ Quality & Safety in Healthcare Conference. Paris, 11-Apr-14

1. ColaLife | What we've learnt from Coca-Cola.
Taking ColaLife to scale in Zambia. 11-Apr-14

2. What is ColaLife and who am I?
ColaLife is a charity registered in the UK
Charity number: 1142516
• No paid employees
• Five voluntary trustees
• Focus on saving children’s lives
• Independent
• Our only project is in Zambia
• Looking for global impact through
• Disruptive innovation
• Generating robust evidence
• Sharing findings and learning
• No commercial interest
2009 2010 2011 2012 20131985

3. The other members of the ColaLife team
2009 2010 2011 2012 20131985
Rohit Ramchandani
Jane Berry

4. 1985 | Our starting point
Coca-Cola seems to get everywhere in
developing countries, yet life-saving
medicines don't. Why?

5. Coca-Cola seems to get everywhere in
developing countries, yet life-saving
medicines don't. Why?
Coca-Cola seems to get everywhere in
developing countries, yet life-saving
medicines don't. Why?
1985 | Our starting point

6. Child mortality in less
developed countries is
unacceptably high.
In 1985 1 in 5 children
didn’t make it to their 5th
birthday (now it’s 1 in 8).
1985 | The ColaLife idea was born

7. The public sector struggles
to maintain reliable
supplies of drugs to health
facilities.
Child mortality in less
developed countries is
unacceptably high.
1 in 8 children don’t make
it to their 5th birthday.
1985 | The ColaLife idea was born

8. The public sector struggles
to maintain reliable
supplies of drugs to health
facilities.
Child mortality in less
developed countries is
unacceptably high.
1 in 8 children don’t make
it to their 5th birthday.
Yet you can get a Coca-Cola
in the most remote, rural
villages.
1985 | The ColaLife idea was born

9. The public sector struggles
to maintain reliable
supplies of drugs to health
facilities.
Child mortality in less
developed countries is
unacceptably high.
1 in 8 children don’t make
it to their 5th birthday.
Yet you can a Coca-Cola in
most remote, rural villages.
Why don’t we put
medicines in Coca-Cola
crates?
1985 | The ColaLife idea was born

10. 1985 | The ColaLife idea was born

11. Why not put ORS & Zinc Kit in Coca-Cola crates?

12. 1985 | No technology to enable sharing of the idea

13. May 2008 | Gordon Brown’s Business Call to Action

14. May 2008 | Set-up Facebook Group

15. … and with international good practice (WHO/UNICEF, 2009)
also including Lancet 2013 series on nutrition/diarrhoea – Apr-13
Strengthened
distribution systems and
new delivery strategies
Diarrhoea treatment
kits for all new
mothers… combining
ORS and Zinc
Market-based solutions are often the most effective
way to deliver key diarrhoea control commodities
We know what to do…
but access and
availability are barriers
“

16. Jun 2010 | Gave up jobs to try and get a trial started

17. Jun 2010 | Gave up jobs to try and get a trial started
Our kitchen table
UK

18. Jun 2010 | Gave up jobs to try and get a trial started
Rohit on Skype
Canada
Our kitchen table
UK

19. Jun 2010 | Gave up jobs to try and get a trial started
Rohit on Skype
Canada
Harvard & UNICEF
on speaker phone
USA
Our kitchen table
UK

20. Sep 2010 | Cycle ride across France raised £6,000

21. Oct 2010 | First of three trips to Zambia

22. Jun 2011 | Partnership and trial plan in place

23. Nov 2011 | COTZ Funders in place

24. Dec 2011 | COTZ gets underway

25. Dec 2011
The trial timeline

26. impac
t Mothers in underserved rural
communities increase use of ORS and
Zinc in home treatment of diarrhoea
purpose
Target communities in two under-served
rural districts have improved access to
ORS and Zinc
outputs
Profit-driven supply chains improve
availability of ADKs (anti-diarrhoea kits)
in targeted communities in two
underserved rural districts
Mothers/care-givers demonstrate
awareness of ADKs and the benefits of
the contents (ORS, Zinc and Soap)
access = ADK in the
hand of an aware
mother/care-giver
Availability = ADK in
stock in retail outlets
at community level
Generating robust evidence - the COTZ results framework

27. Early 2012 | Pre-trial focus group work
What we learnt
Litre sachets are too big
Measuring water was an issue
Willingness to pay
Preferred branding

28. Mar 2012 | Finalised the Kit Yamoyo design

29. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive

30. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml

31. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml
• Packaging is also:

32. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml
• Packaging is also:
• A measuring device for
the water

33. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml
• Packaging is also:
• A measuring device for
the water
• A mixing device

34. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml
• Packaging is also:
• A measuring device for
the water
• A mixing device
• A storage device (the
soap tray is a lid)

35. Mar 2012 | Finalised the Kit Yamoyo design
Kit Yamoyo
• Attractive
• ORS sachets are 200ml
• Packaging is also:
• A measuring device for
the water
• A mixing device
• A storage device (the
soap tray is a lid)
• A cup

36. The COTZ trial
Research Design & Methodology
Quasi-experimental,
pre-test, post test
design
Baseline, midline and
endline surveys
Target groups:
Care-givers of under-5
children and private
community retailers
Four Districts – two
intervention districts
and two comparator
districts
Sample sizes:
625 HH per district
40 retailers per district

37. The COTZ trial
Distribution infrastructure and value chain
Pharmanova MSL Coca-Cola
wholesalers
• Standard Sales (2)
• Isusya’s
Approximately
85 retailers
across Katete
and Kalomo
Manufacture &
Assembly
Lusaka to
District
District to
Retailers
Mothers &
Care-givers

38. >26k
kits sold into the
two remote rural
trial areas in
12 months.

39. >26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.

40. >26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.

41. >26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.

42. 14The perception of
ORS as an
effective
treatment for
diarrhoea
increased by 14
percentage
points.
>26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.

43. 14The perception of
ORS as an
effective
treatment for
diarrhoea
increased by 14
percentage
points.
>26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.
4%Only 4% of kits
went into Coca-
Cola crates. It
was the space in
the market not
the space in the
crates that was
important.

44. Although we used Coca-Cola wholesalers, only 4% of the retailers used this space in
the crate to transport Kit Yamoyos. Many bought by the box full. Working capital was
not an issue.
The value chain is the key enabler. In Zambia, it’s the space in the market, not the
space in the crates that is important.
This means we can revisit the packaging to make it cheaper.
The vision The practice

45. 14The perception of
ORS as an
effective
treatment for
diarrhoea
increased by 14
percentage
points.
>26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.
4%Only 4% of kits
went into Coca-
Cola crates. It
was the space in
the market not
the space in the
crates that was
important.
6International
awards for health
and design
innovation &
6 countries
interested in
replication.

46. Awards | The Kit Yamoyo has won many global awards

47. 14The perception of
ORS as an
effective
treatment for
diarrhoea
increased by 14
percentage
points.
>26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.
4%Only 4% of kits
went into Coca-
Cola crates. It
was the space in
the market not
the space in the
crates that was
important.
6International
awards for health
and design
innovation &
6 countries
interested in
replication.
...Request access
to our findings
colalife.org/
openaccess

48. 14The perception of
ORS as an
effective
treatment for
diarrhoea
increased by 14
percentage
points.
>26k
kits sold into the
two remote rural
trial areas in
12 months.
45%of children in trial
areas received
ORS/Zinc. Up
from a baseline
of <1%.
Comparator sites
stayed at <1%.
2.4km
The distance to
ORS/Zinc in the
trial areas was
reduced by two-
thirds from
7.3km to 2.4km.
93%of Kit Yamoyo
users mixed ORS
correctly. Only
60% do when
given 1 litre
sachets.
4%Only 4% of kits
went into Coca-
Cola crates. It
was the space in
the market not
the space in the
crates that was
important.
6International
awards for health
and design
innovation &
6 countries
interested in
replication.
...Request access
to our findings
colalife.org/
openaccess

49. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Only include
blister pack
Soap
Produce locally
Leaflet Packaging
Remove
constraint of
fitting in Coca-
Cola crate
Produce locally
Produce re-fill
option
Oct 2013 | Incorporating the learning into the scale-up

50. Learning: number of Kit Yamoyo ORS sachets used

51. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Only include
blister pack
Soap
Produce locally
Leaflet Packaging
Remove
constraint of
fitting in Coca-
Cola crate
Produce locally
Produce re-fill
option
4Oct 2013 | Incorporating the learning into the scale-up

52. Learning: Kit Yamoyo Zinc adherence – days Zinc taken

53. Designing for better Zinc adherence

54. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Design the
blister pack to
enhance
adherence to
the 10-day
regime
Blister pack
needs no box
Soap
Produce locally
Leaflet Packaging
Remove
constraint of
fitting in Coca-
Cola crate
Produce locally
Produce re-fill
option
4Oct 2013 | Incorporating the learning into the scale-up

55. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Design the
blister pack to
enhance
adherence to
the 10-day
regime
Blister pack
needs no box
Soap
Produce locally
Leaflet Packaging
Remove
constraint of
fitting in Coca-
Cola crate
Produce locally
Produce re-fill
option
4Oct 2013 | Incorporating the learning into the scale-up

56. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Design the
blister pack to
enhance
adherence to
the 10-day
regime
lister pack needs
no box
Soap
Produce locally
Leaflet
Simplify –
single fold.
Same leaflet
for all formats
Packaging
Remove
constraint of
fitting in Coca-
Cola crate
Produce locally
Produce re-fill
option
4Oct 2013 | Incorporating the learning into the scale-up

57. 4Revised Kit Yamoyo leaflet

58. ORS
Reduce number
of sachets to 4
NOTE: This will
also enhance
adherence
Zinc
Produce locally
Design the
blister pack to
enhance
adherence to
the 10-day
regime
Blister pack
needs no box
Soap
Produce locally
Leaflet
Simplify –
single fold.
Same leaflet
for all formats
Packaging
Remove
constraint of
fitting in Coca-
Cola crate. Only
4% of retailers
used this option
Produce locally
Produce re-fill
option
4Oct 2013 | Incorporating the learning into the scale-up

59. Kit Yamoyo Screw-top
• Attractive and functional
• A measuring device for the water
• A mixing device
• A storage device (screw-top)
• A cup
• And can be re-used
Kit Yamoyo Flexi-pack
• A cost-saving, space-saving option
• Plastic pouch that measures water
• Refill option for the Screw-top
• Currently being tested by CHAI
Kit Yamoyo designs for the scale-up

60. TARGET unsubsidised retail costs (Kwacha)
Screw-top Flexi with soap Flexi w/out soap
Components
ORS (4 sachets) 0.9000 0.9000 0.9000
Zinc (1 blister pack of 10 tablets) 1.0000 1.0000 1.0000
Soap (25g anti-bacterial) 0.4400 0.4400 0
Leaflet 0.2000 0.2000 0.2000
Packaging
Container 0.9100 0.2000 0.2000
Bags and carton (per kit) 0.1200 0.0240 0.0240
Assembly 0.5000 0.2500 0.2500
TOTAL 4.0700 3.0140 2.5740
MSRP 8.00 6.00 5.00
Assumed margins: Manufacturer/distributor 20%; Wholesaler 20%; Retailer 35%

61. Scale-up strategy - Zambia
Community-based marketing (all markets)
Not yet
commercial
markets
Commercial
markets
KZF/iDEPharmanova
Monitoring & Learning
Not yet
commercial
markets
Collaborators

62. Scale-up strategy - Global
Open source – sharing
colalife.org/openaccess

63. So what did we learn from Coca-Cola?

64. The COTZ trial
What we learnt from Coca-Cola – the value chain
Pharmanova MSL Coca-Cola
wholesalers
• Standard Sales (2)
• Isusya’s
Approximately
85 retailers
across Katete
and Kalomo
Manufacture &
Assembly
Lusaka to
District
District to
Retailers
Mothers &
Care-givers
Value
Kit Yamoyo

65. ColaLife uses mobile phones to: provide an authentication system for the Kit Yamoyos;
to deliver a Special Offer (50% off your next purchase); to allow promoters to activate
vouchers before distribution and for voucher redemption by retailers.

66. The COTZ trial
What we learnt from Coca-Cola – the value chain
14 Jan via
You can get any commodity/service to
anywhere in the world by creating &
sustaining demand & making it
profitable to fulfill that demand
TweetDeck
@51m0n
Simon
Berry

67. The COTZ trial
What we learnt from Coca-Cola – the last mile for consumer goods

68. Feb-14 | Chimtende, Katete
Like us on
Facebook
(please):
Facebook.com/c
olalife

69. To be continued…
colalife.org
simon@colalife.org
jane@colalife.org
rohit@colalife.org

70. The data contained in this presentation are unpublished and based
on preliminary analysis of data from the ColaLife Operational Trial
in Zambia (COTZ). Final calculations may vary and will be published
in peer reviewed literature in due course.
In the interim, the following citation may be used: Ramchandani, R.
et al. (2014). ColaLife Operational Trial Zambia (COTZ) Evaluation.
Johns Hopkins Bloomberg School of Public Health, Baltimore.
Related correspondence should be sent to Rohit Ramchandani
(roramcha@jhsph.edu) and copied to Simon Berry
(simon@colalife.org).
A note on the data contained within this presentation