PAK 2001/008: Performance Evaluation of the IDD Control Program (2000-2001)
In 1994, the Government of Pakistan launched a national Iodine Deficiency Disorders Control Programme (IDDCP) to improve the health status of the population. Universal Salt Iodination (USI) was considered as the most cost-effective strategy. To achieve the objective of USI, both the supply and demand creation components are required. On the supply side, the program has involved the private sector in the processing and marketing of the iodized salt. For the demand creation aspect, the program used, for the most part, media campaign to raise awareness of IDD and benefits of iodized salt consumption. In addition, attempts have been made to enact USI legislation as well as to establish a regular monitoring system for iodized salt.
Purpose / Objective
The present study aims to evaluate the on going IDD Control Programme from the perspective of these major stakeholders. The specific objectives of the study are:
- to determine the achievements made thus far in the Programme against set objectives and targets related to both the supply and demand components with regards to: programme design and policy, production and marketing of iodized salt, communication campaign for iodized salt using both mass media and interpersonal communications, household access and consumption level of iodized salt, and quality assurance and monitoring
- to identify constraints faced by both the private sector (salt processors, wholesalers and retailers) and public sector (especially health sector) at national, provincial and district levels as well as by consumer households
- on the basis of insight gained on the prevailing conditions, to draw future recommendations on possible improvements or modifications in the implementation of the national IDD Control Programme
- to provide an information base for generating ideas and taking decisions on sustaining as well as replicating the success demonstrated in pilot districts of the NWFP, using the decentralized district approach
To achieve these objectives, a three-pronged approach has been adopted, which includes the following. First, direct interviews were held with stakeholders to assess their level of knowledge, attitude and practice (KAP) on IDD and iodized salt. Four KAP questionnaires were designed to conduct a nationally representative sample of salt processors (70 in number), wholesalers (500), retailers (500), and households. In addition, information has been collected on the use of iodized salt, its availability, as well as marketing and promotion strategies used by wholesalers, retailers and salt processors. Second, field and laboratory analyses of iodized salt samples were undertaken to determine the iodine content in salt. The field test was performed using Rapid Test Kit and the laboratory analysis was done using the Titration Technique, which was conducted at the National Institute of Health (NIH). Third, the results of the Swat District Model were examined and the (national) project documents were reviewed to compare the results with the rest of the country and to assess the feasibility of its replications. This was done to determine the cost-effectiveness of the IDDCP in the pilot district and to draw implications for other parts of the country.
Key Findings and Conclusions
Based on these surveys, the study found that the awareness about IDD and iodized salt has increased over the years. The awareness is highest among salt processors, followed by wholesalers, retailers and households, in this order. Whereas 70.9 percent of households covered in the survey are aware of the iodized salt logo, this percentage is 84.7 for retailers, and 95.7 for wholesalers and salt processors. Compared to this, the general awareness about iodine deficiency disorders (IDD) is not as high, especially among households (43.9 percent) and retailers (43.3 percent). Also, the population is not as fully aware of the health consequences of IDD. It was found that respondents are generally more familiar with goiter than the other serious health complications.
Despite the ongoing promotional campaign through print and electronic media, the current consumption of iodized salt is not high. Only 27.4 percent of households in the sample were found to be currently consuming iodized salt. This compares with 40.2 percent among retailers' and 57.2 percent among wholesalers' sample. The low demand was due to various reasons. The households believed that iodized salt is relatively expensive as compared to ordinary salt. Similarly, there are widespread concerns about rumors related to family planning. About 26.3 percent rural households are not currently consuming iodized salt because it is not available in their area.
With regard to future demand prospects, the study found that more than 63.0 percent of households, 66.0 percent of retailers and 80.5 percent of wholesalers are willing to use iodized salt in future. This implies that if iodized salt is made readily available, the level of consumption could potentially increase rapidly.
To maintain constant supply of iodized salt, the salt processors are generally relying on government outlets for subsidized potassium iodinate for salt iodination. However, many of them confirmed that they face difficulties in obtaining potassium iodinate from the existing supply set-up.
Beside assessing knowledge, attitude and practice among stakeholders, the study also analyzed salt samples to determine the iodine level in salt at various stages of production, marketing and final consumption at the household level against the recommended iodine levels. Based on field and laboratory investigation using rapid test kit and titration technique, it was observed that malpractice was widespread in the iodized salt business. The salt analysis results revealed that at least one third of the iodized salt supplied by salt processors, wholesalers and retailers did not contain iodine. The quality control and monitoring issues should be a cause of concern for Programme Administrators.
The review of related material on Swat Model suggests that the objective of universal salt iodination has been achieved in Swat. The present study confirmed that there is a higher level of awareness in Swat district about iodized salt and complication arising due to its deficiency in human body as compared to other parts of the country. The current use of iodized salt is also much higher (93.3 percent) in Swat than national average. It was found that majority of Swat residents are able to purchase iodized salt from nearest markets. All salt samples collected from Swat areas were iodine fortified. This indicates that both demand creation and supply side policies are being effectively pursued in Swat. Since this progress has been accomplished at a very low cost (Rs. 0.19 per beneficiary), the Model has the potential to be replicated in other parts of the country.
The analysis of survey data, salt samples and the comparison of Pilot District results with the rest of the country have shown that a lot has been achieved over the past years in terms of raising awareness (demand creation) and the smooth supply of iodized salt. A majority of the respondents, especially the urban households, confirmed that they face little or no difficulty in purchasing iodized salt. However, monitoring and quality control areas need strengthening. A number of future recommended strategies and plan of action have been suggested on the basis of the findings of the study to improve upon this situation.
The most important step for the success of any project is its well thought-out plan. In the case of the salt iodination program, it is necessary to design stepwise strategies for enhancing demand and ensuring constant supply.
In view of the limited current use, it is necessary that awareness be raised through electronic and print media by focusing on the health consequences of iodine deficiency. The misinformation campaign, which is having an adverse impact on the success of the Programme, needs to be tackled in an effective manner. To discredit family planning rumor, the media campaign needs to be more focused. To avoid similarities between the IDD campaign message and the family planning advertisement, the study recommends that the color of the iodized salt logo be changed.
It was observed that even though salt iodination increases the cost of production by only a few paisas, iodized salt is sold at almost double the price of ordinary salt. This rent-seeking behavior should be discouraged. Effort should also be made to ensure price stability without sacrificing the quality of iodized salt.
On the supply side, the active involvement of the private sector needs to be revamped. The need for further strengthening of the incentive structure is evident from the fieldwork. In this respect, the subsidization of potassium iodinate should continue as it encourages salt processors to remain in the salt-iodination business. The incentive structure should also involve wholesalers and retailers, so that they also play their role in the constant supply of iodized salt. The role of retailers is pivotal in the overall supply chain, but they are seldom approached either by the Programme Administrators or other relevant agencies.
A serious observation of the study is the lack of quality control and monitoring. Even though the 1996 Appraisal Report also raised the issue of the quality of iodized salt, nothing or very little has been gained on this front between 1996 and 2001. The unprofessional conduct continues to be widespread in the iodized salt business. The study found that ordinary salt is being sold in iodized salt packets. It is recommended that a certification method should be implemented for suppliers of iodized salt, to discourage malpractice. Fictitious labeling should strongly be discouraged. The possibility of printing expiry date on iodized salt packets by salt processors could also be explored to avoid the consumption of iodized salt that has already expired. This effort needs to be supplemented through regular monitoring. For this, inter-departmental and community collaboration may be sought. In other words, the Swat Model should be replicated in the rest of the country. This may require approximately Rs. 30 million additional resources (19 pasia per beneficiary), which is not a big amount when health complications due to IDD are taken into consideration
Finally, for an effective implementation of the IDDCP, a training program needs to be strengthened for those involved in the monitoring of the iodized salt. It would require involvement of the community, whose services may be desired to internalize the program for its long-term sustainability. Once internalized, it is expected that the community will itself take control of it without an active involvement of the Government and other agencies.
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