Quest towards Eliminating Iodine Deficiency Disorders

COMMENTARY

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Quest towards Eliminating Iodine Deﬁciency Disorders

Chandrakant S Pandav, Anna Somos-KRishnan, Arijit Chakrabarty, M G Karmarkar

To eliminate iodine deﬁciency, India needs to adopt an alternative approach and use a different set of agents to achieve universal salt iodisation.

Chandrakant S Pandav (cpandav@iqplusin.org), Arijit Chakrabarty (ac@iqplusin.org) and M G Karmarkar (mgkarmarkar@gmail.com) are with the Centre for Community Medicine at the All India Institute of Medical Sciences, New Delhi and Anna Somos-Krishnan (as2913@columbia.edu) is with the School of International and Public Affairs, Columbia University, New York.

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april 25, 2009

n south Asia, India is the second worst performer after Myanmar in consumption of adequately iodised salt, which has a well-known effect of preventing the population from mental and physical impairment, brain damage, and endemic goitre. Only 50% of Indians consume adequately iodised salt, which is far behind the leading countries – Bhutan (95%) and China (93%). We often hear the following apology from companies and governments: “…but who has the money to reach out to everyone?” This excuse seems rather lame if we closely look at the ofﬁcially estimated cost of iodine deﬁciency disorder (IDD) elimination. To date, salt iodination remains the most practicable and affordable method of iodine supplementation. As a commodity it is consumed in a ﬁxed quantity on a daily basis by both the rich and the poor and on the consumer an additional cost of only Rs 2 per person per year in India (Sood et al 1997). In Switzerland, the elimination of IDD through the mandatory production and marketing of iodinated salt in the country, was completed in less than a decade and has been reported by Swiss scientiﬁc and medical authorities to have been the most cost effective public health measure in their history. The total cost was about US 20 cents per person for a decade! The Federal Republic of Germany in 1992 reported expenditure by insurance companies of 2 billion deutschmarks (about $1 billion) to correct problems of iodine deﬁciency and thyroid, revealed only after uniﬁcation of the country (Haxton 1993). In order to understand what the historical facts behind these recommendations are, we sequenced the major milestones of the past 50 years of IDD combat in India. The third National Family and Health

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S urvey (NFHS) (2005-06) shows that only 51% of the households of India are using adequately iodised salt, which gives enough reasons to worry that something has gone seriously wrong at all levels of IDD elimination.

Milestones in Quest for USI

Since its inception in 1962, the National Goiter Control Programme (NGCP) remained a low priority health programme for the government as “goiter” was mainly considered a “cosmetic” problem and goiter did not cause any pain. In addition India was struggling with control of communicable diseases (small pox, cholera, tuberculosis) that were responsible for large number of deaths. The turning point in the programme implementation in India came about after a meeting where the then Prime Minister Indira Gandhi who recognised the implication of IDD on brain development and that IDD was a public health problem in India. She took immediate action for the liberalisation of production of iodised salt. This marked the ofﬁcial ownership transfer from government to private sector. The Central Council of Health and the Technical Review Committee along with the government decided to launch the Universal Salt Iodisation (USI) Programme in 1983 with private sector participation.

Activity of Multilateral Agencies

In India, the International Council for Control of Iodine Deﬁciency Disorders (ICCIDD) works in collaboration with the All India Institute of Medical Sciences in New Delhi, The Micronutrient Initiative (MI), UNICEF and WHO. The acti vity of these multilateral organisations would ensure sustained advocacy, communication (awareness campaign), and tracking progress independently. UNICEF/MI/ICCIDD have even stepped beyond their normal capacity and set up iodisation units in several locations. In Rajasthan, the World Food Programme (WFP) in collaboration with the MI is using a new model of organising small-scale salt

COMMENTARY

Figure 1: Salt Iodisation – Real Progress?

c onsumption 76.1%, is not necessarily a

Production against requirement of iodised salt in India (million tonnes)

bad result, because it shows that people

6

1970-85 1994-95 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07

system in place to monitor the salt that moves

2 per mov avg production Requirement Production

by road. Most of the states, which perform

Source: ICCIDD booklet Salt for Freedom and Iodised Salt for Freedom from Brain Damage, October 2007.

poorly, receive salt which moves by road. producers into associations to help increase of the country was to receive iodised edible (2) Unless the individual state governments their capacity to iodise their product. salt containing minimum 15ppm (parts per go on a mission mode to check the entry of

Besides India, private sector run iodisa-million) iodine. To ensure the success of the non-iodised salt mostly transported by road, tion plans (received from multilateral USI, in 1998 the government implemented it will be difﬁcult to achieve more than 90% development agencies) have been tried in a central ban on the sale of non-iodised coverage. Also once achieved it has to be sus-Bangladesh, Nepal, Myanmar, Indonesia salt for human consumption. Two years tained as evidenced by the case of Madhya and Pakistan. Though done with good later due to political and administrative

Table 1: Short-changing the Customer

intentions but in reality it is not to the scale compulsions, it withdrew this legislation.

State % of % of Qualityso as to sustain IDD elimination (Hetzel There was no comprehensive strategy to Households Households Delivery Gap

Consuming Consuming (Claimed

2002). The missing element of these initia-ensure the supply of iodised salt. While the

Adequately Claimed Adequate)tives is the market-based involvement of production of iodised salt has increased in Iodised Salt Iodised

(Quality Tested) Salt

the private sector to cater to the demand recent years (Figure 1), the hard facts

Mizoram 85.9 98.8 12.9

generated by all the communication and point out that the available salt, is inade-

Arunachal Pradesh 83.6 98.8 15.2

the awareness building by the multilaterals. quately iodised. It is critical to differentiate

Manipur 93.8 98.8 5

It is important to note that salt/iodised salt between available total production and

Nagaland 83.3 97.8 14.5

is a product of the market. In general, no available adequately iodised salt produc-

Assam 71.8 97.2 25.4

government or NGO makes salt on a scale tion. This myth explains how the govern-

Tripura 75.5 97.2 21.7 to meet the national demand and sustain ment of India has consistently showed Sikkim 78.3 97.1 18.8 it. However, there is no evidence of a busi-progress in recent years, but in reality no Meghalaya 81.9 97.1 15.2 ness model that incorporates the pro-poor progress has been realised in USI. Bihar 66.1 94.7 28.6 business approach, which ensures sustain-The quality of iodisation in the available Himachal Pradesh 82.5 94.1 11.6 ability and long-term continuation of the salt is so poor that in certain states it exceeds West Bengal 69.1 93.3 24.2

Jharkhand 53.6 92.7 39.1

projects. The next step therefore has to be 40% of the quality delivery gap (Table 1).

Delhi 86 91.9 5.9

the opening up of dialogue between the Given the size of the country, in India

Jammu and Kashmir 75.8 90.5 14.7

multilateral organisations, government and there is an immense market opportunity

Punjab 74.6 85.8 11.2

the private sector to transfer ownership. for producers. We logically expect thus that

Kerala 73.9 82.6 8.7

Examining both the supply and demand such interventions, as banning the sales of

Chhattisgarh 54.9 79 24.1

angle of the salt market, the potential non-iodised salt, the extraordinary efforts

Goa 64.8 77.3 12.5 reasons why iodised salt consumption is by multilaterals to create a demand would Uttar Pradesh 36.4 76.6 40.2 insufﬁcient, are twofold: have an immediate and stimulating effect Orissa 39.6 76.1 36.5 Demand: (1) People are unaware of the on the private sector to produce more and Maharashtra 61 74.3 13.3 health beneﬁts of iodised salt, and (2) Peo-sell more high quality salt. Gujarat 55.7 72.1 16.4 ple cannot afford to buy the product. Against all our expectations, in India, Haryana 55.3 71.8 16.5

Uttarakhand 45.9 71 25.1

Supply: (1) The iodised salt is not available however, both the consumption and the

Karnataka 43.3 66 22.7

on the market, and (2) People are not aware production of iodised salt has dropped.

Tamil Nadu 41.3 65.5 24.2

that the salt which is claimed to be iodised Figure 1 shows Indian salt production in

Rajasthan 40.8 63.3 22.5

contains insufﬁcient amount of iodine. the ﬁrst years of the policy, and the

Andhra Pradesh 31 60 29

To regulate the supply side, the govern-im mediate decrease after the ban was

Madhya Pradesh 36.3 58.7 22.4

ment of India adopted a policy of USI in lifted. From a social development perspec-

India 51.1 76.1 25 1984, under which the entire population tive, the national average of claimed Source: Columbia University Analysis 2007 based on NFHS-3, 2007.

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COMMENTARY

Pradesh, where the coverage has slipped during these years as the mission mode could not be sustained. (3) The rural population and the people of low socio-economic status continue to be deprived of adequately iodised salt. Only 30% households in the lowest wealth quintile use adequately iodised salt. Most of the states that have iodised salt available in the public distribution system (PDS) ensure better availability to the vulnerable population at an affordable price. It also generates a market demand for the producer to produce adequately iodised salt. (4) The salt producing states have wider quality gap. This is because of the local movement of salt by road for internal use.

Sustained and effective information, education and communication (IEC) campaigns are expensive. For, e g, an IEC campaign cost in the year 1999-2000 for the Pulse Polio Eradication Programme was Rs 145 crore out of a total budgetary allocation of Rs 545 crore (Ministry of Health and Family Welfare Annual Report 1999-2000). This is 26% of the total budget, whereas the total budgetary allocation for National Iodine Deﬁciency Disorders Control Programme (NIDDCP) in the same year was a meagre Rs 7 crore. Moreover the time taken for behaviour change is longer than project periods of multilateral organisations, which are usually of shorter duration requiring deliverables in that time frame. IEC campaigns thus should thus be built into the national programmes so as to be deliverable and sustainable. Thus, multilateral organisations have been slowly reducing the frequency of awareness campaigns. A campaign cost is way above the costs of building rural distribution channels or local iodisation plants. The problem is that the private sector has not fully recognised customer demand, which would be likely to be met by building new channels or ensuring the quality standards of iodisation. Awareness campaigns only lead to real impact if the salt is consistently supplied to the educated consumers.

As is the case of pulse polio, awareness campaigns should be done by all (government, private sector, national and international NGOs). The demand and supply is not an either or situation. It has to be a concerted and harmonic approach.

It is clear that the Indian salt industry is currently not recognising the demand for

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april 25, 2009

good quality iodised salt, and does not seem to care on delivering the product to all segments of the society. Field research repeatedly highlights the myth of price sensitivity.

Research efforts clearly point to the fact that:

The low-income segment of the Indian population, despite all development efforts do not consume sufﬁciently iodised salt not because they cannot afford to buy the good quality product, but because either the product is not available in rural markets or the claimed iodised salt is of questionable quality.

The following three reasons probably explain the reason for the gap in quality of iodisation and deﬁne our challenges.

(1) Many small-scale Indian salt manufacturers do not have a consistent, quality-controlled iodisation technology, (2) Quality conscious consumers need assistance to uncover the inconsistency of iodine level; for example with the wide spread availability of testing kits, and (3) There is a pivotal role for the branded players of the salt market to standardise quality and effectively deliver the product to the entire country.

How to Make It Work?

This model assumes a private sector approach. The government’s effort, taking into consideration the administrative and political environment, has been p eriodic, instead of being comprehensive and sustained.

The value chain of the iodised salt consists of many steps:

major public health concern, having an impact on the health of many millions of children and women.

(1) Salt Production – Estimate the capacity and quality requirements of iodised salt producing plants to fulﬁl demand: After a thorough demand-estimation in each state, the production capacity of the private sector should be increased. The current production of branded players should approach the real demand. The demand estimation should also entail the difference in consumer preferences regarding the use of free ﬂowing or crystallised salt.

(2) Salt Iodisation – Empower and unite the current 819 iodisation units across the country under one quality control system: If the technology of salt iodisation is registered or trademarked, it becomes an intellectual property. This allows producers to claim certain standards of iodisation and preserve the quality of their product. It is essential that not only branded players but everyone is protected from infringement – which is often coupled with extremely poor quality – of salt production. Additionally, if any of the companies decide to franchise the iodised salt production to local plants, it is inevitable that the company owns the right of that process and controls the quality standards attached to it.

(3) Salt Trading – Approach all ration shopdealers across India: Salt traders are key actors of the value chain of salt. They have a pivotal role in salt procurement in those states where the political lobby makes it difﬁcult to regularly obtain large quantities

Ensure that in each state of India the production capacity meets the demand.

Establish joint effort (producer-trader) in those states where traders expressed interest in selling iodised salt as opposed to unprocessed salt.

Educate retailers on the benefits of iodised salt and revisit the margin they apply to the product.

Agencies should monitor health improvement, establish school performance indicators, and measure

Salt production Salt iodisation Salt trading

Distribution, Transportation

Retail and Storage

the children’s progress.

Each step has a crucial role and has an impact on the operational success of the entire iodised salt value chain. The current malfunctioning of the above process, which mainly originates from the lack of synergy of each step, results in IDD still being a

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Consumption

salt consumption and have the opportunity to test the salt they consume.

Development impact Register and trademark the technology of salt iodisation and create feasibility study for setting up iodisation units across the country.

Involve the rural communities by assigning the distribution task to community groups by creating additional livelihood for them.

Ensure that all consumers are aware of the importance of iodised

at a stable price. While salt traders have access to the raw material, they do not have the means for iodisation. If traders recognised the value of selling iodised salt versus raw material, then the private sector should fulﬁl this role and provide the means.

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Furthermore, ration shops (government licensed and subsidised retail facilities to cater to the poor – the public distribution system, PDS) across India are one possible way to make sure that the low-income population gets the high quality iodised salt. This requires persistent discussion with the state governments. At present, except for a few states, there is no salt product available in the PDS.

(4) Distribution and Transportation: Distribution deﬁcit is one of the key factors. The government of India has a policy in place to give priority to movement of iodised salt by rail (Currently in category “C”. Recommendations are on the table for upgrading to the pre-existing category “B”.). However, on a more economically sustainable manner, local communities have to be involved in salt distribution. Branded players can channel the salt distribution through community groups (self-help groups). The compensation of this activity would provide additional livelihoods for the group members, as evidence shows already in many states of India. This requires a concerted effort of the NGOs and the private sector.

Schools and anganwadis should be other key centres of large quantity salt distribution. Mid-Day-Meal programmes, and the Integrated Child Development Services Scheme in many places are reported to be using branded salt. However, they procure it on the retail market at a much higher price. Targeting these institutions with a clear strategy means a signiﬁcant penetration to the market.

(5) Retail and Storage – Engage and build relationship with all the retail units that sell branded salt: Evidence shows that it is often the retailer’s choice what type of salt gets into the consumers basket. Retailers should be aware of the health beneﬁts of iodised salt and the price implications of it. A transparent monitoring system, where retailers are audited on the margin they apply to the product, would help to sell more of the high quality product. By strengthening the demand side, the low-income communities will make a conscious effort to buy the good quality product, which leaves no room for retailer manipulation, i e, selling low q uality salt brands.

(6) Consumption – Supply all consumers with an iodine testing kit attached to the salt package: This is the element of the

value chain that mainly drives the proﬁt of branded iodised salt. Unless consumers are educated and assisted to make the “healthy choice” as opposed to the poor quality, the company will not make a headway in this market. Despite the myth that poor people are not concerned about quality, most poor women in the towns are willing to pay as much as Rs 10 for a packet of branded salt to ensure the health of their children.

Promoting iodine-testing kits attached to the salt package would not only sustain the “iodine consciousness” of the consumers but would also attach “quality delivery” as an attribute to any existing salt brand. On most occasions the smaller packages of salt are packed in larger bags of 25/50 kgs. A few salt testing kits can be attached to these bigger packs to help the retailer check the salt in front of the consumer. This will not only generate awareness, but also ensure that the retailer gets adequately iodised salt.

(7) Development Impact – Reach 0% IDD prevalence in India by 2015: It is absolutely critical that development professionals are also involved in the IDD elimination process. They have a key responsibility to educate people on the beneﬁts of iodised salt in those areas where the salt is available. The current situation awareness campaigns are almost meaningless because of the quality delivery gap or the supply d eﬁcit of the iodised salt. Therefore solving the latter should be a key priority.

Development agencies should be more proactive in seeking the market-based solutions with the private sector players. They also should practise their role more proactively to facilitate the cooperation between the government, the communities, and the large salt producers. This means initiating action in the ﬁeld, facilitating continuous discussions with all stakeholders. A good example of this is the Bavishya Alliance’s work in Maharashtra, which provides a platform for government, community groups, private sector and multilaterals to work on comprehensive solutions (e g, cooking and hygiene practices).

Conclusions

Health issues are social, political and economic issues. In the formulation of policy in a democratic environment we require identiﬁcation and recognition of the health

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problem/issue; information to know and critically ﬁlter evidence-based data and an effective and efﬁcient intervention to eliminate the problem. More over, we also require formal networks, stakeholder alliances and informal networks and most importantly address the socio-cultural-political aspects related to public health problems as reﬂected in the values, beliefs and interests. Implementation of policy, if based only on one or two factors, will not only achieve less results, but also lead to a r etrograde step as seen in the case study of NIDdCP. According to the latest NFHS-3 – only close to 51% of the India’s population has access to adequately iodised salt.

It is also important to note that the rural population and the people living in the low socio-economic status continue to have poor access to adequately iodised salt. Also noteworthy is the fact that salt predominantly transported by rail has better levels of iodisation as compared to the ones that are transported by road. This is evidenced in the north-eastern states where the households have a high percentage of coverage.

It is also noteworthy that household coverage is better in those states that have iodised salt available in the PDS. Channelling the product from the small- and mediumscale producers to large-scale consumers like the state PDS and the ICDS scheme would generate a market for these producers.

Therefore, it is obvious that in order to build permanent and sustainable solutions, we should stop procrastinating and take action to start a form of multi-stakeholder alliance addressing the most urgent issues. Until we do so, we may lose the intellectual capital of 13 million newborn children every year.

References

Annual Report (1999-2000): Ministry of Health and Family Welfare, Government of India.

Haxton, David P (1993): “Private Enterprise-Public Health, An Expanding Alliance” as published in First Call for Children, New York.

Hetzel, Basil S (2002): Eliminating Iodine Deﬁciency Disorders – The Role of the International Council in the Global Partnership (Geneva: Bulletin of the World Health Organisation).

India (2000): National Family Health Survey-2, 1998-99, International Institute for Population Sciences (IIPS) and Macro International.

– (2007): National Family Health Survey -3, 2005-06, International Institute for Population Sciences (IIPS) and Macro International.

Sood, A, C S Pandav, K Anand, R Sankar and M G Karmarkar (1997): “Relevance and Importance of Universal Salt Iodisation in India”, The National Medical Journal of India, 10 (6): 290-93.

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