7 Point Plan
A 7-point plan for
comprehensive diarrhoea control
We know what needs to be done to reduce the burden of childhood diarrhoea.
A package of proven prevention and treatment measures are now available that,
if taken to scale, would have a profound impact on reducing child deaths and
would lead to a significant reduction in the diarrhoea burden in the medium
to long term.
The treatment package focuses on two main elements, as laid out in the UNICEF and WHO
2004 joint statement:43
1. Fluid replacement to prevent dehydration
2. Zinc treatment.
Oral rehydration therapy is the cornerstone of fluid replacement. New elements of this approach
include low-osmolarity ORS, which are more effective at replacing fluids than the previous ORS
formulation, and zinc treatment, which decreases diarrhoea severity and duration. Important additional
components of the package are continued feeding, including breastfeeding, during the diarrhoea
episode and use of appropriate fluids available in the home if ORS are not available.
The prevention package focuses on five main elements to reduce diarrhoea in the medium to long term:
3. Rotavirus and measles vaccinations
4. Promotion of early and exclusive breastfeeding and vitamin A supplementation
5. Promotion of handwashing with soap
6. Improved water supply quantity and quality, including treatment and safe storage of household water
7. Community-wide sanitation promotion.
New aspects of this approach include rotavirus vaccination, which was recently recommended for
global introduction (Box 10). In terms of community-wide sanitation, new approaches to increase
demand to stop open defecation have proven more effective than previous strategies.
It is important that implementation of the prevention package is approached in a concerted way,
since single interventions alone are likely to result in lesser overall impact. For example, diarrhoea
caused by rotavirus cannot be prevented solely by improvements in water and sanitation. And
rotavirus vaccine does not prevent other pathogens (such as E. coli and Shigella) from causing diarrhoea.
The package should be accompanied by clear, targeted and integrated behaviour and
social change communication strategies to improve uptake by families and communities.
Action needed now to reduce child deaths from diarrhoea
- Mobilize and allocate resources for diarrhoea control. Diarrhoea remains a leading killer of
children, though the tools needed to address it are available and affordable. New resources for
child survival must include funding for diarrhoea prevention and treatment. And global initiatives
must keep the management of diarrhoea high on the list of priorities for public health resource allocation, including rotavirus vaccination,
which has now been recommended for global introduction. At the same time, national and
district health planners should include diarrhoea control in programmes targeting childhood
malaria, pneumonia and HIV, and ensure support to accelerate coverage of proven interventions.
- Reinstate diarrhoea prevention and treatment as a cornerstone of community-based primary
health care. To effectively control diarrhoea, treatment and prevention measures should be
integrated into the training of health workers and reflected in supply chains and programme
monitoring. Expanding the reach of health services into communities to deliver integrated
interventions is critical. These include community-based promotion of breastfeeding, hygiene and
sanitation and the provision of low-osmolarity ORS and zinc to children with diarrhoea.
- Ensure that low-osmolarity ORS and zinc are adopted as policy in all countries. Clear policy
guidance is needed to ensure that the latest recommendations for treating childhood diarrhoea are adopted and promoted, using effective
delivery strategies. One way of facilitating the delivery of low-osmolarity ORS and zinc is by
combining these life-saving remedies in a single treatment kit.
- Reach every child with effective interventions. This will require a flexible approach that takes
into account the special circumstances of each country; often it will require a mix of public and
private sector responses. Community-based approaches are needed to ensure high coverage of
health, nutrition and water and sanitation interventions, rather than relying solely on the public
sector for these services. Emergency and conflict situations may require immediate intervention by
governments and international aid organizations, especially to prevent cholera outbreaks.
- Accelerate the provision of basic water and sanitation services. This can best be accomplished
through partnerships between the health sector and other agencies responsible for water
and sanitation, and the use of community-based approaches. Eliminating open defecation must be
a priority, along with promoting the construction of basic sanitation facilities by households and
providing safe water facilities close to people’s homes that can be operated and maintained by the community.
- Use innovative strategies to increase the adoption of proven measures against diarrhoea.
All available options should be exploited to reach every household with a package of high-impact
interventions against diarrhoea (Box 11), including the testing of new approaches to achieve
high and equitable coverage. This could include, for example, the development of flavoured ORS
formulas or systems for treating and safely storing household water. Other types of innovations
include alternative delivery strategies, such as Child Health Days, to reach a high proportion of
the target group. Consumer research to improve packaging, marketing and product positioning
will be essential for greater acceptance of ORS, soap and household water treatment.
- Change behaviours through community involvement, education and health-promotion activities.
Clear and targeted health promotion and behaviour change communication programmes must accompany
the delivery of interventions to ensure that caregivers understand the simple actions they can
take at home to prevent and manage diarrhoea. Engaging communities and caregivers early
on – at the outset of programme planning – to strengthen their knowledge and practice of these
essential measures is critical to their success and sustainability.
- Make health systems work to control diarrhoea. National governments and their partners can
transform general activities to strengthen health systems into specific agreements needed to reach
every child with effective measures to control diarrhoea. These include meeting the need for
human resources, reducing staff turnover, improving training programmes and seeking creative
ways to motivate community health workers.
- Monitor progress at all levels, and make the results count. As national programmes accelerate
their diarrhoea control activities, it will become increasingly important for countries to collect,
analyse and report quality data in a timely manner to monitor programmes and increase accountability
- Make the prevention and treatment of diarrhoea everybody’s business.
- Families and communities can ensure that breastfeeding, handwashing, sanitation and
the treatment of household water receive the priority they deserve. They must also be supported
in working with government to access safe water supplies and to operate and maintain
water supply systems once they are built. Everyone from adolescents and schoolteachers
to religious leaders and local business people can get involved.
- The public sector can advance comprehensive prevention and treatment programmes at both
the national and local levels, not only through the ministry of health but also through agencies
involved in education, commerce, water and sanitation, nutrition, women’s affairs and urban
and rural development.
- The private sector can promote innovation in the supply and delivery of key interventions,
in partnership with public institutions.
- Government leaders can expand public awareness of the problem and its solutions, thereby
increasing demand for services to reduce deaths from diarrhoea.
- Global partnerships and networks can forge new links across initiatives, leading to strong
and effective advocacy and reducing the risk of competing activities.