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Aim  This paper aims to identify factors that systematically predict why some countries that have tried to scale up oral rehydration solution (ORS) have succeeded, and others have not.    Methods  We examined ORS coverage over time, across countries, and through case studies. We conducted expert interviews and literature and data searches to better understand the history of ORS scale–up efforts and why they failed or succeeded in nine countries. We used qualitative, pairwise (or three–country) comparisons of geographically or otherwise similar countries that had different outcomes in terms of ORS scale–up. An algorithm was developed which scored country performance across key supply, demand and financing activities to quantitatively assess the scale–up efforts in each country.    Results  The vast majority of countries have neither particularly low nor encouragingly high ORS use rates. We observed three clearly identifiable contrasts between countries that achieved and sustained high ORS coverage and those that did not. Key partners across sectors have critical roles to play to effectively address supply– and demand–side barriers. Efforts must synchronize demand generation, private provider outreach and public sector work. Many donor funds are either suspended or redirected in the event of political instability, exacerbating the health challenges faced by countries in these contexts. We found little information on the cost of scale–up efforts.    Conclusions  We identified a number of characteristics of successful ORS scale–up programs, including involvement of a broad range of key players, addressing supply and demand generation together, and working with both public and private sectors. Dedicated efforts are needed to launch and sustain success, including monitoring and evaluation plans to track program costs and impacts. These case studies were designed to inform programmatic decision–making; thus, rigorous academic methods to qualitatively and quantitatively evaluate country ORS scale–up programs might yield additional, critical insights and confirm our conclusions.

Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low– and high–performing countries