Tracking Progress Towards Sustainable Elimination of

Iodine Deficiency Disorders (IDD)in India:

Partnership at State, Regional & National Levels

Dr Denish Moorthy, Dr C S Pandav, Dr R Sankar, Prof M G Karmarkar

All India Institute of Medical Sciences (AIIMS), Indian Coalition for Control of Iodine Deficiency Disorders

(ICCIDD) &

The Micronutrient Initiative (MI)

Chandigarh28th – 29th February 2004

Outline of Presentation

1) Success in Public Health

2) Research to Policy to Program: The Iterative Loop

3) Partnerships in Public Health

4) Tracking Progress Towards Sustainable Elimination of IDD in Kerala & Tamil Nadu

Success in Public Health

1) Well-defined research question

2) Sound scientific research protocol with qualitative and quantitative components

3) State specific information

4) Inter-disciplinary approach

5) Participatory approach

6) Partnership with private sector

7) Linking research with decision making process Mr. P Hota, Secretary to the Government of India, Department of Family Welfare,

Ministry of Health & Family Welfare

Iterative LoopResearch-Policy-Program

POLICY

RESEARCH PROGRAM

Adapted from: Tugwell P, Bennett KJ, Sackett DL, Haynes RB. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis. 1985;38(4):339-51

Iterative LoopResearch-Policy-Program

RESEARCH

POLICY

PROGRAM

Partnerships

Generate Relevant Research Questions

Adapted from: John Hubley. Communicating Health. An action guide to health education and health promotion

List of questions

Prediction from theories

Discussion with field workers & community

Experience

Reading the research

findings of other people

Decisions Needed by the

Program

Partnerships in Public Health

Why Partnerships?

1. “The main determinants of health & disease lie outside

the realm of direct medical competency” – Sir Douglas

Black, Past president of Royal College of Physicians,

London

2. No single sector -- governmental, commercial or civil

society - has the necessary skills or resources to alone

do what is necessary in all areas

3. For e.g. Business has many types of skills and expertise

needed for effective health improvement

4. Partners share objectives and risks regardless of 1. Different contributions from each partner

2. Different benefits to each partner

Partnerships in Public Health - 1

1. Polio Eradication (Rotary International with WHO, Sovereign

Governments)

2. Iodine Deficiency Disorders Elimination (Kiwanis International,

UNICEF, ICCIDD, WHO,PAMM)

3. Children’s Vaccine Initiative (Rockefeller Foundation, UNDP,

UNICEF, World Bank, WHO, private sector)

4. GAIN (Global Alliance for Nutrition – WHO, Private Industry,

Sovereign Governments)

5. Global Fund for AIDS, TB, Malaria (Sovereign Governments,

WHO, CDC, USAID)

6. Supercourse (Internet for Global Preventive Health) –

www.pitt.edu/~super1/ - Awareness about Prevention

Partnerships in Public Health - 2

6. Mectizan Donation for Onchocerciasis (Merck Inc, WHO)

7. Grameen Bank (Microcredit for poverty eradication – community

partnership)

8. Public-Private Partnerships (PPP) in Healthcare to Deliver the Essential

Services Package (ESP) as part of the Health and Population Sector

Programme (HPSP), Government of Bangladesh, 1999-2004

(Government of Bangladesh, DFID, NICARE/British Council, NGOs)

9. TB & You (Forging partnerships with NGOs (Bangladesh Rural

Advancement Committee),Media, Private Health Sector (Andhra

Pradesh – State TB Unit and Private Hospital), Policy Makers, Donor

Agencies)

Partnerships for Public Health in India

Tracking Progress Towards

Sustainable Elimination of Iodine

Deficiency Disorders (IDD) in

Kerala and Tamil Nadu, India

Studies in Kerala, Tamil Nadu and Orissa, Bihar

Tamil Nadu

Orissa

Kerala

Bihar

The Kerala Study

Kerala

Kerala Study - Partners

1) Government of Kerala

2) Government Medical Colleges

3) State Nutrition Lab

4) IndiaCLEN

5) Indian Medical Association

6) ICCIDD

7) UNICEF, India

Process of Partnership

1) Enrollment of Stakeholders

2) Partnership & Planning

3) Partnership in Data Collection & Dissemination of result

4) Political Advocacy and Follow-up

May 2000

June 4th 2000

June 5th 2000

June 5th 2000

Advisory Committee Meeting

Meeting with Mr. Rajeev Sadanandan, Secretary Health,

Government of Kerala

Meeting with Prof. K Leelamoni,Dr. Rajamohanan, Dr. Vijayakumar

Dept. of Community Medicine,Medical College, Thiruvananthapuram

Meeting with Mrs. M S Subhadra,Directorate of Medical Education

Enro

lment o

f Sta

kehold

ers

Indian Medical Assn. & IndiaCLEN

Enrollment of Stakeholders

• Foundation: sound science

• Established coalitions (IndiaCLEN)

• New linkages (IMA)

• Meeting with highest policy makers (Secretary Health)

• Clarity of proposal

• Work ethics: A professional approach

June 2000

July – October 2000

October 24th & 25th 2000

November 29th 2000

UNICEF/ICCIDDas a stakeholder

Preparation of Draft ProtocolInteraction with Prof. Leelamoni,

Mr. Rajeev Sadanandan

Training & Orientation WorkshopProtocol Finalization

Debriefing WorkshopFinalization of field study schedule

Partn

ersh

ips a

nd

Pla

nnin

g

Capacity BuildingSense of Ownership

Joint EffortSense of Involvement

in the study

Training,Quality Assurance

Partnership & Planning

• Recognized international technical bodies: ICCIDD/ UNICEF

• Capacity Building: Key issues sorted out by state investigators themselves

• Sense of ownership of data: Own efforts

• Sense of involvement in the study

• Thorough training on all aspects of the survey

• Quality assurance: Training and application

January 2001

March 2001

April 29th 2001

Field Study(All Medical Colleges)

Laboratory Analysis (DHS)Data Analysis (Medical College,

Thiruvananthapuram)

Dissemination Workshop

Partn

ersh

ips in

Data

C

olle

ction &

D

issem

inatio

nCapacity Building

PartnershipSense of Ownership

Capacity BuildingPartnership

Sense of Ownership

Government (Central & State), Academia,NGOs, Experts, Nutritionists

Activists

June 2001

August 2001

May 2002

Meeting with Mr Ramesh Chennitala, MP from Kerala

Meeting with Mr A K Antony, Chief Minister of Kerala

Official release of the Kerala Report byMr P Sankaran, Health Minister of Kerala

Politica

l Ad

voca

cy a

nd

Fo

llow

up

Sensitization ofpolitical leadership

Sensitization ofpolitical leadership

Follow up Activities

Dissemination of Results, Political advocacy & Follow up

Dissemination

• Transparency: Protagonists and Antagonists of the USI strategy invited; Everyone’s views were considered

Follow-up

• Development, coordination and expansion of political influence

• Sensitization of the public

• Follow-up activities

• Regular feedback

• Catalytic role of credible agencies: UNICEF/ICCIDD

• A collaborative exercise: a joint effort

Criteria for Tracking Progress Towards Eliminating IDD As A Public Health

Problem

Indicator Goal Kerala

Thyroid size ( age group 6-12 years)Proportion with enlarged

thyroid (1067 subjects)

<5% 16.6%(95% CI - 14.4 – 18.8

%)

Median Urinary Iodine (µg/L)

(990 Subjects)> 100 123.3

( Range 10.2 - 378 g/L)

Salt iodisationProportion of Households

consuming adequately iodised salt

(1065 samples)

>90% 48.9%(95% CI - 45.9 – 51.9

%)

The Tamil Nadu Study

Tamil Nadu

A Collaborative Project BetweenDepartment of Public Health and Preventive Medicine,

Regional Health & Family Welfare Training Centres

Food Analysis Laboratories

Government Medical Colleges

Government of Tamil Nadu

National Institute of Epidemiology, ICMR, Chennai

National Institute of Nutrition, Hyderabad

India Clinical Epidemiology Network (IndiaCLEN)

All India Institute of Medical Sciences, New Delhi

The Micronutrient Initiative, New Delhi

Indian Coalition for Control of

Iodine Deficiency Disorders (ICCIDD)

United Nations Children’s Fund (UNICEF), Tamil Nadu

• Tamil Nadu 30 Clusters

IDD Study in Tamil Nadu - Objectives

1. To assess current status of IDD in Tamil Nadu

using WHO/UNICEF/ICCIDD Criteria

2. To determine availability and cost of

adequately iodised salt at the household level

in Tamil Nadu

3. To assess the community’s perception towards

IDD, salt & iodised salt in Tamil Nadu

Training Workshop at IPH, Poonamallee

28-30 November 2002

1) Training, Field Study, Laboratory Analysis: Department of Public Health and Preventive Medicine, Regional Health & Family Welfare Training Centres, Food Analysis Laboratories, Government Medical Colleges, Government of Tamil Nadu

2) Data Entry and Analysis: National Institute of Epidemiology, ICMR, Chennai

3) Laboratory Analysis and External Quality Assurance in Salt iodine analysis: National Institute of Nutrition, Hyderabad

Roles and Responsibilities - 1

4) The Qualitative Study: India Clinical Epidemiology Network (IndiaCLEN)

5) Overall Coordination, Technical Expertise: All India Institute of Medical Sciences, New Delhi, Indian Coalition for Control of Iodine Deficiency Disorders (ICCIDD)

6) Main Funding Agency: The Micronutrient Initiative, New Delhi

7) Additional Funding for Training & Dissemination: United Nations Children’s Fund (UNICEF), Tamil Nadu

Roles and Responsibilities - 2

Criteria for Tracking Progress Towards Eliminating IDD As A Public Health

Problem

Indicator Goal Tamil Nadu

Thyroid size ( age group 6-12 years)Proportion with enlarged

thyroid (1230 subjects)

<5% 13.5%(95% CI-11.6 – 15.4%)

Median Urinary Iodine (µg/L)

(1206 Subjects)

> 100 89.5( Range 2.0 – 422.1

g/L)

Salt iodisationProportion of Households

consuming adequately iodised salt

(1228 Samples)

>90% 18.2%(95% CI-16 – 20.4 %)

Dissemination Workshop5th June 2003

Organized by the Government of Tamil Nadu

Participants:

Government of Tamil Nadu & Its Agencies

Tamil Nadu Salt Corporation

National Institute of Epidemiology, ICMR, Chennai

National Institute of Nutrition, Hyderabad

All India Institute of Medical Sciences, New Delhi

IndiaCLEN

The Micronutrient Initiative, New Delhi

Indian Coalition for Control of

Iodine Deficiency Disorders (ICCIDD)

United Nations Children’s Fund (UNICEF), Tamil Nadu

Recommendations

• Establishment of an IDD Review Committee at the Department of Public Health & Preventive Medicine

• Awareness generation – In the community through television & radio– Grassroot level workers through the health

system

• Production level monitoring

• Cyclic monitoring

Tracking Progress Towards Sustaining Elimination of IDD in

Kerala

Tracking Progress Towards Sustaining Elimination of IDD in

Tamil Nadu

Dissemination Workshop5th June 2003

AdvocacyDemand Creation

Monitoring

Health Minister

Sec Health

Panchayat Raj Members

District Magistrates}

AwarenessMonitoring

Activities Related to Supply Side

Increase in Iodised Salt Production

Capacity of TNSC

Salt & Iodized Salt

Producers Meeting}

Ensuring Quality, Accessibility. Availability, Affordability, Acceptability

of Iodised Salt

The Tamil Nadu IDD Study and Follow Up Process

Success in Public Health

1) Well-defined research question

2) Sound scientific research protocol with qualitative and quantitative components

3) State specific information

4) Inter-disciplinary approach

5) Participatory approach

6) Partnership with private sector

7) Linking research with decision making process Mr. P Hota, Secretary to the Government of India, Department of Family Welfare,

Ministry of Health & Family Welfare