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The USI Pakistan Program- A Success Story

Iodine deficiency is the worlds single greatest cause of preventable mental retardation. Iodine

is part and requirement of a hormone, thyroxin,

which is responsible for optimal mental and

physical development, physical growth and

reproduction, maintenance of a person's

metabolic rate and helps the white cells to

inactivate bacteria. Goiter-the enlargement of

the thyroid gland (located at the base of the

neck) is also caused by a lack of iodine in a

person's diet. The most severe impacts of iodine

deficiency occur during fetal development and

in the first few years of life.

The global strategy of choice for preventing

iodine deficiency disorders (IDD) is universal salt

iodization (USI). Because salt is commonly

consumed, even in impoverished areas, it is an

ideal vehicle to carry iodine. Adding iodine to

salt provides protection from brain damage due

to iodine deficiency for whole populations,

helping people and countries reach their full

potential. While complete iodization of a

nations salt supply may not always be possible,

generally USI is considered successful if greater

than 90% of households are using iodized salt.i

Its been more than half a century when Iodine

Deficiency Disorder (IDD) was recognized as a

public health problem in Pakistan, a country

with more than half of the population

estimated to be at risk for Iodine Deficiency

Disorders as reflected in various surveys.

In 1989 the Government of Pakistan initiated a

National Iodine Deficiency Disorders (IDD)

Control Program to address the problem of IDD,

however, its impact remained limited due to the

limited knowledge & capacity of the salt

processors required for iodization, irregular and

centralized supply of Potassium Iodate (KIO3),

absence of a monitoring and supervisory

mechanism, lack of a quality control system,

weak regulatory framework along with various

rumours from consumer side and even after

many years of running of program the

utilization of iodized salt at the household level

could only reach 17 percent by the end of 2001

(UNICEF 2001-02).

In 2005 Micronutrient Initiative (MI), a leading

Canadian Non Governmental Organization

working exclusively to eliminate vitamin and

mineral deficiencies in the worlds most

vulnerable populations came forward and

carried out the first ever Pakistan Salt Sector

Survey to document the weakness and bottle

necks of the salt industry of Pakistan.

According to the survey out of the total of 0.935

million tons of edible salt processed by 1172

salt units in Pakistan at that time, only 14% was

iodized (MI-2005). Among these salt units 68

percent were small scale and more than 80

percent of them had no formal training on salt

iodization. In addition to this most of them

didnt even have the necessary equipment for

salt iodization.

In the light of the findings of this survey and

lessons learnt from the previous National IDD

Control Program, Nutrition Wing of Ministry of

Health revitalized the USI program in Pakistan

with the technical and financial assistance of MI

(getting its funding from Canadian International

Development Agency (CIDA) in 2006.

Initially the Universal Salt Iodization (USI)

program was piloted in 20 districts selected

from all over Pakistan with the salt processors

provided with iodization equipment along with

training on iodization technique and internal

quality control. Government Health officials

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were also provided trainings on supervision,

monitoring of USI Program, external quality

control and in compilation and analysis of

iodization data. As the strategies adopted in the

pilot districts brought about a positive change in

salt iodization, therefore WFP joined hands in

the efforts towards control of IDD and the

Program was scaled up by including 29 high risk

northern districts of Khyber Pakhtoonkhwa (KP),

Azad Jammu & Kashmir (AJ&K), Gilgit Baltistan

(GB) and Federally Administered tribal Areas

(FATA). Community awareness and capacity

building of public health care providers, school

teachers and NGOs were also important

components of the program. During 2007,

program was further expanded to 16 large salt

producing districts of Punjab, contributing

about one third of the total edible salt

production in the country. By 2008, the salt

iodization at the production level increased

remarkably from less than 14% to 65% in these

districts as reported by the monitoring system

of Department of Health. Strong coordination

among partners, capacity building of the

government and salt industry, and provision of

KIO3, drip feeders, and other equipment

needed for salt iodization to the salt sector and

most importantly, a phased wise expansion of

the program contributed to the success of the

USI in Pakistan . The encouraging USI results

and requests from Department of Health on the

other hand led the total number of districts

being covered by the Program to reach 102 by

2010.

By this time the program had achieved 99

percent of salt iodization in the country as per

findings of the assessment of salt iodization at

production and focus was towards

improvement in the level of adequate iodization

of salt. For this purpose Quality Control

Laboratories (QCLs) have been established in

the salt producing districts. District focal

persons and MI field officers collect salt samples

from the salt processors and take it to QCLs

where they are analyzed quantitatively for their

iodine content. If the iodine content is found to

be below 30 ppm, the salt processor is notified

about it for taking corrective measures. At the

same time through provision of technical

support the Program has built the capacity of

the government health managers in external

monitoring and quality control, streamlining the

regulatory and enforcement mechanism and

internal quality control to ensure adequate

production of iodized salt. With the coordinated

efforts of MI, WFP and the Departments of

Health, district level legislation and notifications

on compulsory USI and pure food rules

amendments were enacted in 56 districts of

Pakistan during 2009-11. In the absence of

national or provincial legislation these were

used for enforcement of salt iodization at the

district level which yielded positive results.

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Furthermore, throughout these years emphasis

has been placed on involving the salt producers

as equally important partners in the USI

Program. They have been supported to form

associations at the Provincial & District level

that have facilitated USI activities and

coordination amongst Program partners. The

USI Program is spread out in all provinces,

Punjab, Sindh, Balochistan, KP, AJ&K; GB &

FATA with the objective to improve the

availability and accessibility of adequately

iodized salt to the vulnerable sections of the

population.

According to the National Nutrition Survey

2011, around three-fourths (69 percent) of the

households in Pakistan now consume iodized

salt compared to 17 percent in 2001, which is

very encouraging for the USI Program. The

increased consumption of iodized salt has led to

a decrease in the percentage of children 6-12

years of age with iodine deficiency by 28

percent (i.e. NNS 2011-36 percent: NNS 2001-

64 percent). Prevalence of goiter amongst

women of childbearing age has also decreased

to one third as per NNS of 2011 and now stands

at only 3 percent.

Comparison of urinary iodine excretion in mothers and school aged children between NNS 2001 & 2011

Till 2008 Potassium iodate (KIO3) premix with

refined salt (NaCl) was being given in small

packing of 500 grams to minimise misuse and to

ensure its availability at district level for small

scale salt processors. However, since 2009, KIO3

was provided in pure form on subsidized rates

by the government with support of MI and

WFP. Keeping in view the long term

sustainability of the program, MoH after

consultation with USI partners, withdrew

subsidy on KIO3 with effect from July 2012 in a

phased manner leading to a complete

withdrawal in March 2013. A revolving fund was

established for procurement and supplies of

KIO3 to salt processors on no profit no loss

basis. The first procurement with the revolving

fund has been carried out and from April 2013,

KIO3 is being given to the salt processors on the

actual cost. Legislation on compulsory salt

iodization is already in place in Gilgit Baltistan

and most recently in Sindh. It is now important

to ensure that the legislations are enforced in

remaining provinces/regions thus ensuring that

the salt processors produce, promote and sell

only adequately iodized salt.

USI Programs phased expansion over the years,

a strong commitment and ownership by the

government, an excellent coordination and

partnership amongst USI partners and a

stringent monitoring in the field have all

positively contributed to the success of the this

program.

The challenge, however, does not end here. To

further build and sustain this achievement there

is need for a strong political commitment and

salt industry motivation. During the coming

years, the USI Program focus will be to provide

technical and operational support to salt

processor units for adequate iodization of salt

to the government in monitoring and quality

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control. The USI program will be expanded to 8

additional (remaining) salt producing districts of

Sindh that are not covered by the Program so

far, thus bringing the total number of USI

districts to 110. Efforts would be made towards

the development of an open market system of

procurement and availability of the KIO3.

Advocacy will be carried out with the salt

processor associations to motivate them to

arrange for the replacement of equipment

themselves on self help basis. Priority will be

given to the component of quality control in

program implementation to ensure adequacy of

edible salt iodized and necessary steps taken in

this respect. In those provinces that do not

have compulsory salt iodization legislation,

advocacy will continue with government

departments and stake holders for

promulgation of provincial legislation on

mandatory salt iodization.

i (Assessment of Iodine deficiency disorders and monitoring their elimination. 2007, WHO.)