The work of the Micronutrient Initiative in Asia. 1
Reducing zinc and other deficiencies. 4
Wheat Flour Fortification to Reduce Anemia: 8
Support to national actions to reduce and control VMD.. 12
Reducing zinc and other deficiencies. 15
1. The Asia region has an alarmingly high burden of VMDs.
2. MI works in the highest burden countries: Bangladesh, India, Nepal and Pakistan. MI works closely with Government, local NGOs, donor agencies such as CIDA and USAID, and UN organizations such as UNICEF and WFP. In 2005, MI also initiated programs in Sri Lanka, China and Indonesia.
á Bangladesh: In 2005 MIÕs work focused on the delivery of vitamin A supplements (VAS), soy bean oil fortification and universal salt iodization (USI) programs.
á India: MIÕs work in India continued to focus on VAS, an expansion in USI and various programs to address anemia, including programs delivering fortified candies which were taken up by many state governments. In 2005 MI established the MI India Trust was established and started work with the World Food Program (WFP) to support iodization within the small-scale salt industry.
á Nepal: Despite the difficult political situation, MIÕs work in this country continued to produce innovation and efforts continued in the areas of anemia supplementation and fortification.
á Pakistan: MIÕs focus in Pakistan was on VAS and USI, and on raising new resources . The MI office was very active in pursuing RX opportunities. MI played a leading role in ensuring that children affected by the earthquake were given vitamin A capsules. MI has been selected by the Government of Pakistan to implement the GAIN-supported national wheat flour fortification program.
á China: MI will be partnering with UNICEF China office to increase salt iodization consumption in low coverage areas. This advocacy program hopes to reach 32 million people in 3 years.
á Indonesia: MI in partnership with KFI (Coalition for Fortification, Indonesia) will support the national Vitamin A supplementation program and will survey and repair salt machines that when operation will produce iodized salt to reach an additional 2 million persons.
á Sri Lanka: In Sri Lanka MI will be assisting in the rehabilitation and refurbishing of two salt factories. The rehabilitation of these two factories is expected to double coverage of adequately iodized salt from the current 40% level to 80% of the Sri Lankan population (14 million people).
3. The focus will continue on protecting and expanding coverage of VA supplementation for children 6-59 months and on scaling-up the coverage of iodized salt. Anemia programs such as fortified candies in India, and wheat flour fortification in Pakistan will continue to be part of the portfolio. MI Asia will work with others to generate funding for new programming and to increase capacity to respond to emergencies in Asia, and will continue its work in developing national investment plans
4. Bangladesh has an u5MR of 69[1] and is therefore a priority country for MI. In 2005, vitamin A supplementation coverage was 85%. MIÕs highest priorities in this reporting year were to sustain high coverage for VAS and to increase coverage with iodized salt by resolving bottlenecks impeding progress in production of salt, and support to national actions to reduce and control VMD.
5. This year the MI continued to be a major player in the area of micronutrients in Bangladesh. MI, at the request of CIDA, undertook a scoping mission to identify organizational options and feasible services for nutrition in Bangladesh. After extensive discussions with stakeholders at all levels and an intensive field visit, a consultative workshop chaired by the Secretary of Health and attended by key health and nutrition related persons in Dhaka, was held. The consultation recommended organizational options and documented lessons learned. The policy makers have incorporated these recommendations into the Project Implementation Plan of the Health Nutrition and Population Sector Program - which have been approved but not yet officially implemented by the government.
6. In 2005, programs supported by MI in collaboration with partners in Bangladesh resulted in the majority of children receiving vitamin A capsules, the initiation of vitamin A fortified soybean oil program, up-grading of salt iodization plants and the initiation of a pilot program to increase the micronutrient status of adolescent girls. These efforts resulted overall in over 27 million beneficiaries being reached by programs supported at least in part by the MI .
7. MI did not provide capsules in 2005 as the Government procured the capsules themselves.
8. The main thrust next year will be to focus efforts of upgrading the salt iodization plants and continued support for the VAS distribution program. In addition, MI will initiate a new project to reach hard to reach children. This year also saw the launch of the vitamin A fortified soybean oil project: MI will continue to provide technical support as well as funds for the fortificant so as to reach even greater number of the population.
VAS programs:
9. The VAS program in Bangladesh has been able to achieve high rates of coverage for the past few years targeting children 6-59 months through twice annual vitamin A campaigns. In 2005 the Government of Bangladesh procured its own capsules and has confirmed procuring capsules for 2006 and 2007. In 2005 MI supported both rounds of the campaign by funding 50% of the costs; UNICEF funded the remainder. The coverage estimated for both rounds is 85% as per reporting through routine monitoring (IPHN) and nutrition surveillance conducted by IPHN/HKI. MI worked closely with the Government and other partners such as UNICEF in the planning stages. In 2005, MI retained a consultant to work specifically on the VAS program. This enabled the close coordination with partners and helped to ensure successful joint results. Our initial estimate indicates that over 40,000 childrenÕs lives were saved based on 2 rounds of coverage for 2005.
10. The joint MI/UNICEF country assessment of the VAS program in 2004 recommended new and innovative approaches to reach 15-20% of the hard to reach. A strategic plan has been developed and it will be rolled out in 2006. The twice yearly vitamin A campaign approach with other health/nutrition messages will continue in 2006. MI will continue to support the vitamin A campaigns by providing funds and technical support and by implementing specific approaches to reach the hard to reach.
VA fortification programs:
11. MI initiated a large pilot program for soybean oil fortification – initially in collaboration with the International Life Science Institute (ILSI) to demonstrate feasibility and effectiveness. In 2005 MI entered into a contract directly with an oil entrepreneur (who controls 30% of the market share) after which fortification equipment was put in place with technical support from MI; MI also supported the project by providing premix. Based on this pilot, other oil refineries have expressed interested in fortifying their product. MI aims to mobilize wider support from other donors to fulfil this need.
Iron-folic acid tablets:
12. This year, MI piloted a project with Health Promotion Limited (a local NGO) to provide iron and folate supplements to adolescent girls of 16 -19 years of age through village level community workers for womenÕs health. A total of 63,000 girls were reached. The pilot project is to end in 2007 and an evaluation will be conducted after which recommendations are to be developed. It is hoped that this pilot will be expanded and that the girls will procure the tablets on their own from the women community workers who will serve as depo-holders. The pilot will also hopefully serve as a model to incorporate into the Health, Nutrition and Population Sector Program (HNPSP).
Iodized salt:
13. In 2005 MI initiated a project to upgrade salt iodization plants. The first part of the project consisted of an assessment or survey of existing plants in a few zones which was completed in July 2005. The second component was to upgrade five SIPs, which was completed and in addition, 15 more plants were upgraded by the last quarter of 2005. Therefore, in 2005 a total of 20 plants were upgraded. As part of the project, two government officials were also sent to India for exposure and training. In 2006 MI plans to upgrade an additional 20 plants and conduct surveys in 2 more zones.
14. In 2005 MI worked with the International Zinc Consultative Group and identified new areas where zinc programming could be initiated. Zinc in complementary foods and as tablets for children were identified as possible priorities. Discussions were held with various organizations, donors and government. Proposals for funding are being developed.
For further information on MIÕs work in Bangladesh, please contact Zeba Mahmud
15. India has an u5MR of 87[2]; 57% of children under five are deficient in Vitamin A; total goiter rate is estimated to be 20%; anemia rates among pregnant women is 51% and for children under five it is 75%[3]. MIÕs highest priorities in this reporting year were to: boost coverage with Vitamin A Supplements (VAS), increase coverage with iodized salt, expand programs to reduce iron deficiency and to increase the flow of resources to micronutrient programming.
Support to national actions to reduce and control VMD
16. The Micronutrient Initiative India Trust: The MI India Trust has been created to simplify the operations and implementation of programs in India. Registered in May 2005, the Trust has obtained FCRA clearance from the Ministry of Home Affairs, Government of India for both operations and programs in the areas of IDD, VAD and distribution of fortified candies in different States in India. MI will retain its status as a Liaison Office in India, but will also program through the Trust.
17. The MI is presently drafting a National Investment Plan for the prevention and control of micronutrient deficiencies in India. The investment plan offers a practical, results-oriented, and time-bound approach to tackling this "hidden hunger" in India during the five-year period covered by the Government of IndiaÕs next (11th) plan. The investment plan expects to cover 230-300 million high-risk people per year at an additional yearly cost to the Government and development partners ranging from US $100 million to US $145 million (less than 2% of current public expenditure on health in the country). The investment plan is being prepared with a taskforce made up of representatives from government, academic institutions, non-governmental organizations, the private sector and international organizations. It is being developed in response to the increased priority given by the Government of India both to combating malnutrition generally and micronutrient malnutrition specifically.
18. As a first step to disseminating information related to the National Investment Plan, the MI launched a report on ÒControlling Vitamin and Mineral Deficiencies in India—Meeting the GoalÓ on October 18, 2005. Select members of the MI Board met with the President and Prime Minister of India to discuss the investment plan and both have shown keen interest.
o As a follow-up, the Ministry of Food is circulating these reports to the Food, Secretaries across the country.
o The Department of Food & Public Distribution, Ministry of Consumer Affairs, Food & Public Distribution, Government of India has included the MI as one of the Members of the National Alliance Against Hunger.
o The MI has also been included as a Member of the Expert Group constituted by the Ministry of Human Resource Development, Department of Women and Child Development, Government of India, to advise on the norms for fortification of the supplementary food distributed through the ICDS program. A circular to this effect has been issued by the Secretary, Government of India to all the DWCD Secretaries of the State Governments requesting them to initiate use of the iodized salt in ICDS and fortification of ICDS food with different micronutrients. The Ministry has also increased the allocation of resources for the supplementary nutrition component of the ICDS program for fortification. Presently, an additional 100% of the cost has been committed by the Central Government.
Increasing investment in micronutrients:
19. Fortified Lozenges - An outcome of the very positive results of the Efficacy and Effectiveness Study reports on fortified lozenges, a circular was issued by the Government of India to the State Governments to distribute these lozenges through the ICDS programs in their respective states. The fortified lozenges have opened up avenues to expand MI programs with resources from the State Governments. Ten State governments have expressed interest, four of which have already begun programs.
20. DFID was in a dialogue with the Government of West Bengal for supporting the Integrated Health Project for the next five years. The MI took the DFID team on a field visit to West Bengal to showcase some of the successful programs. The Government of West Bengal has also requested DFID to scale up all the ongoing MI interventions presently being implemented in 8 districts to all the 19 districts in the State. DFID has included the MI interventions in the Nutrition Strategy paper developed for the purpose. This is presently pending clearance from the Government of India following which, it is hoped that co-financing of nearly CDN $10 million may become available.
21. The MI will also be an implementing partner of the World Food Program (WFP) for a large project in the State of Rajasthan that will assist the small-scale salt sector to iodize salt.
VAS programs:
22. The VAS Program in India is carried out as part of the Reproductive & Child Health Program (RCH) and is called the National Program for Prevention of Nutritional Blindness (NPPNB). The Program currently focuses on children between the age group of 9 months to 3 years and the delivery mechanism is twice-yearly Òspecial eventsÓ through routine immunization. Due to continuous advocacy efforts by MI and UNICEF, in many states, the state governments have covered children up to 5 years of age and 9 states are using a twice-yearly approach to deliver VAS through month long activities.
23. Reports from the state RCH office are received and compiled by the National RCH program managers, but since the twice-yearly approach has not been integrated with RCH program coverage, data resulting from such an approach are not included and only routine immunization coverage is reported. UNICEF state offices and MI field consultants keep track and integrate such data to obtain the national picture.
24. India is the only country in the world where VA for supplementation is provided in the form of syrup. The syrup is supplied through kits meant for the RCH program. MI provides funds to UNICEF to procure and distribute VA syrup to fill supply gaps at district level and below at the request of the various states. Currently UNICEF provides MI-funded syrup in 15 states. Efforts are on to advocate with Government to minimize supply gaps and to improve the efficiency of the supply chain for VA.
25. MI has been working closely with UNICEF towards institutionalizing the twice-yearly approach in all states and coordinating the program at sub district and district levels through the appointment of district level extenders. In the last year MI has appointed 13 extenders in 3 states and is on the verge of recruiting 10 more extenders in 3 more states. The main role of the district extender is to coordinate the efforts and work closely with the district and sub-district officials so that the VAS program is effectively implemented.
26. Coverage rates in India are reported by FY and the latest estimate for FY 2004/05 is 51% for two doses (as targeted age range) or 34% for children 6-59 months (two doses). As MI supplies 60% of the syrup required for the country through UNICEF.
Coverage for 2 doses |
FY 2001/02 |
FY 2002/03 |
FY 2003/04 |
FY 2004/05 |
As targeted age range |
33 % |
42 % |
45 % |
51 % |
All India 6-59 m |
17 % |
27 % |
31 % |
34 % |
27. 4 states achieved 70% or greater for two doses in 2005: Bihar, Jharkhand, Rajasthan and Tamil Nadu. The total estimated lives saved in 2005 are 94,859.
State |
Lives Saved: Two Rounds |
Bihar |
43,572 |
Jharkhand |
13,649 |
Rajasthan |
27,737 |
Tamil Nadu |
9,901 |
Total |
94,859 |
28. In 2006 the MI plans to continue the district extender-state coordinator model and expand its use to 3-4 new states. Program support areas evolved in discussions with state governments and UNICEF include training of frontline workers, developing and supporting the implementation of urban area strategies, providing mobility support for hard to reach areas, improving monitoring and supervision, IEC and Social mobilization, etc. MI will also support UNICEF in providing the gap supply of VA on request from states while working towards reducing this gap by improving the efficiency of the governmentÕs supply chain.
Double Fortified Salt (DFS)
29. In India, the DFS program so far has been targeted to provide Double Fortified Salt to supervised feeding programs such as school midday meal program, ICDS (Integrated Child Development Services) program and the Public (food) Distribution System (PDS). At an average per capita salt consumption level of 10 g/day, DFS meets an around 30% of the daily iron requirements in the diet.
30. Premix Production: Premix production has been successfully initiated in collaboration with two Indian contract manufacturers. Premix production commenced in March 2005. The product quality as determined by in-house analytical techniques has been established to be on par with the product from North America. In fact, India is well positioned to produce premix that could be exported to other parts of the world.
31. Collaboration with TNSC: MI supported the installation of a Double Fortified Salt manufacturing facility at the Tamil Nadu Salt Corporation (TNSC) Salt Plant, which was completed in June 2004. With around 1.5 tons of premix, TNSC commenced manufacture of DFS and distributed the product for utilization in State Government sponsored Noon Meal Program. Between April and September 2005, MI provided 1 ton of iron premix every month as free subsidy to TNSC which produced 150 tons of DFS catering to around 1.8 million school children in 7 TN districts under the Noon Meal Scheme. The subsidy quota was increased to 2 tons per month of iron premix from October onwards, and the corresponding increase in production of 300 tons per month of DFS is meeting the requirements of the Noon Meal Scheme in all 29 TN districts, benefiting 3.6 million students.
32. Ongoing Studies: A bio-efficacy study on DFS is being conducted by St. Johns Institute of Clinical Health & Population Research, Bangalore in coordination with Swiss Technical Institute (ETH), Zurich. The study is expected to be completed by December 2006. A parallel household DFS acceptability study is being conducted by Institute of Home Economics, University of Delhi, and the results are expected in June 2006.
33. Plans for 2006: are to explore opportunities with salt producers in other States and to continue with premix subsidy of 2 tons per month to TNSC with MI funding to meet the DFS requirements in Tamil Nadu noon meal scheme and on cost recovery basis in 2007; and to forge an agreement with HSL to supply 66 tons of premix at cost over a 1 year period to enable production of 10,000 tons of DFS for distribution in Chattisgarh State through ICDS.
34. Haryana, Punjab and Chandigarh: MIÕs support for commercial fortification of wheat flour at all the large-scale roller mills in the states of Haryana and Punjab, and the Union Territory of Chandigarh, has taken off the ground through the Roller Flour Millers Federation of India (RFMFI), a major body representing the flour industry, to improve the nutrition of approximately 13.5 million people of which 6.6 million are expected to be at risk, by introducing fortified flour fortified with iron and folic acid and processed by approximately 80 millers. The program was launched in January, 2005 and presently around 23 millers are fortifying the wheat flour reaching around 1.46 million beneficiaries
35. Andhra Pradesh: The West Bengal experience has now reached the State of Andhra Pradesh, where the Government is promoting flour fortified with vitamin A, iron and folic acid in 1kg, 3kg and 5kg packs sold at a reasonable affordable cost by the middle income groups. The MI has been on the Expert Committee to provide only technical support in terms of providing the suitable composition of micronutrients, tendering for the premixes, designing of the labels for packing and training of the millers on the process of fortification. This program started at the end of 2005 and the fortified flour is presently reaching about 1 million beneficiaries.
36. Gujarat: The Department of Food & Civil Supplies, Government of Gujarat has issued a notification that ÒAll wheat flour sold in the State of Gujarat needs to be fortified with iron and folic acid w.e.f. January 1, 2005Ó. This is a major step forward in the area of flour fortification in the country wherein, a State Government has taken a lead in making flour fortification mandatory. The State Government is providing support for demand creation by publicity activities both through print and electronic media and is developing a logo for the fortified ÔattaÕ packages. The MI is providing the training inputs and 80% of the premix cost in the first year and 50 % in the second year, following which the cost of the fortified ÔattaÕ will be passed on to the consumer. Around 30 millers are in the process of initiating flour fortification in the State which is expected to reach 1.6 million people per month.
West Bengal Micronutrient Initiative Project Phase II:
37. Wheat Flour Fortification: Phase II of the West Bengal Integrated Micronutrient Initiative Program has completed its first year. The Wheat Flour Fortification initiative in Darjeeling, Kalimpong, Kurseong through the two millers has been regularly reaching to 1.7 million beneficiaries with atta fortified with iron, folic acid and vitamin A.
38. ÔKhichriÕ Fortification at Anganwadi Centre level: Subsequent to the successful feasibility study on reaching fortified ÔkhichriÕ (locally made food) to 0.7 million beneficiaries at the Anganwadi Centre level in Phase I, the same has been scaled up to reach 1.248 million beneficiaries 6 months to 6 years of age and pregnant and lactating mothers, in Phase II covering seven districts in West Bengal. The efficacy study has just been completed by a Ph.D. student from Tufts University and we are awaiting the results. The Government of West Bengal has announced that ÔkhichriÕ fortification will be scaled-up in the whole State of West Bengal at their own cost reaching 7.4 million beneficiaries in the next financial year.
39. Distribution of fortified candies: Distribution of candies fortified with iron, folic acid, vitamin A and vitamin C to children 3-6 yrs of age and pregnant and lactating mothers in Howrah district of West Bengal continues.
Gujarat Micronutrient Initiative Project:
40. Fortified RTE Food : The RTE food fortified with iron, folic acid, vitamin A and vitamin C continues to reach 0.35 million beneficiaries, mainly children 6 months to 6 years of age and pregnant and lactating mothers in four districts of Gujarat. Based on the positive evaluation studies, the Government has now taken a policy decision to fortify the RTE food for under two children across the State which is being supported by WFP.
41. Fortified Lozenges: The existing reach of 0.5 million beneficiaries with fortified lozenges, with iron, folic acid , vitamin A and vitamin C, in 3 districts of the State is now being planned to be scaled up in the entire State of Gujarat through the ICDS program during the next financial year for 3-6 years children and pregnant and lactating mothers.
42. Adolescent Anemia Control Program: With support from the MI, the Government of Gujarat has initiated an iron folate supplementation program to adolescent girls in nine districts of the State reaching about 2.5 million beneficiaries. This initiative has been launched as a follow up of an impact assessment study done in the Baroda district of Gujarat by UNICEF. In partnership with UNICEF, who are supporting a similar initiative in the remaining 16 districts, the Government of Gujarat is presently the only State in the country which is implementing this program across the State, covering all the 25 districts. The Government of Gujarat has indicated to the MI in writing that they will pay for this program with their own resources starting April 1 2006.
43. In India, MI programs on IDD control have largely been focused on the production side of the salt industry where it is felt that maximum impact could be achieved through optimum investment. MIÕs iodine initiative which really took off only in 2003 has two components: (a) intervention in the large scale salt sector and (b) USI promotion by providing support to the small scale sector.
Support to Large Scale Salt Sector:
44. Tamil Nadu Salt Corporation Ltd. (TNSC), a State Government undertaking, with the technical & financial assistance of MI installed and commissioned in February 2004 an iodized salt production facility with designed capacity of 60,000 tons per annum good quality iodized salt to meet the PDS requirements of the South Indian States of Tamil Nadu and Andhra Pradesh. In 2005, MI appointed an engineering consultancy firm to undertake monthly technical audits of this plant and based on their recommendations has supplied essential machinery spares to maintain the factory in good operating condition. In the past year TNSC has produced around 42,000 tons of iodized salt with a reach of 12 million people living below the poverty line.
45. In 2005, TNSC again approached MI for further assistance to augment its present production capacity by 30,000 tons per annum to meet the PDS requirements of salt in a 3rd south Indian state, Karnataka. This project is currently ongoing and the new iodization plant is expected to be commissioned in January 2006 and the expected reach in 2006 would be a further 6 million people living below the poverty line. TNSC has made the following commitments to the MI:
- The increase in iodized salt production as a result of MIÕs intervention would be sold in fair price shops at affordable cost through PDS in Tamil Nadu and Andhra Pradesh.
- Even at the increased capacity, TNSC would continue with its existing system of manual packaging of salt which was being carried out by women from economically weaker sections of society, thereby ensuring their continued livelihood as well as providing employment opportunities for additional labor force.
46. Hindustan Salts Ltd. (HSL), a Government of India undertaking with salt plants in Rajasthan, Gujarat and Himachal Pradesh, approached MI in 2004 for assistance in upgrading its Sambhar Salts plant in Rajasthan. Although Sambhar Salts plant was producing around 70,000 tons per annum of salt, only 6,000 tons were being marketed as edible iodized salt due to capacity and quality limitations. Under the grant provided by MI, HSL is installing a salt washery with iodization unit at Sambhar Salts of 70,000 tons per annum production capacity which is expected to be commissioned in January 2006 and has an expected reach of 12 million people living below the poverty line through PDS in the northern States of Rajasthan, Chattisgarh and Jharkand.
Support to the small scale production sector
47. In its endeavor to promote USI in India, MI is collaborating with ICCIDD involving 3 major activities:
- Potassium Iodate (KIO3) Subsidy for Small Scale Salt Manufacturers
- State level advocacy for improving adequately iodized salt coverage at households
- Quality assurances and monitoring at production level
48. Under the KIO3 subsidy scheme, MI-ICCIDD have appointed Salt Extenders in the 4 salt producing states of Gujarat, Tamil Nadu, Rajasthan & Andhra Pradesh, to identify the potential recipients of this subsidy and also monitor its usage. Nine (9) tons of KIO3 have already been distributed by the end of 2005. These Salt Extenders have also been entrusted with the task of assessing the present condition of iodization units so that these may be made operable. 16 such plants have been targeted for rehabilitation in Andhra Pradesh and the work will be completed by March 2006. This entire exercise is being carried out in close coordination with the Office of the Salt Commissioner of India. MI has commissioned a consultancy to study the salt production and distribution patterns in Tamil Nadu and provide a model framework that will determine the future strategy for KIO3 subsidy and can be replicated in other States.
49. Under the MI-ICCIDD collaboration, meetings have been held with several State Government Agencies including Civil Supplies Corporations to promote the marketing of iodized salt through PDS in these States. An IDD dissemination workshop was organized by ICCIDD in Orissa State. Training Sessions were conducted in coordination with UNICEF in Gujarat, Tamil Nadu, Andhra Pradesh and Rajasthan for small scale salt producers, on proper iodization techniques, plant maintenance and correct analytical procedures. ICCIDD has also been interacting with the Salt CommissionerÕs office to provide quality control assistance to the nodal laboratories of the Salt Department as well as training and capacity building of the officers of the Department.
50. The population reached until the end of October 2005 through the KIO3 subsidy scheme is 22.8 million and is expected to touch 50 million by year end.
Lessons Learned in IDD
¤ The countrywide household coverage of adequately iodized salt was estimated to be only around 37% as per a DHS study of 2003, a fall of around 13% from 2001 levels, despite the strong advocacy and demand creation campaigns undertaken by premier agencies over the past 2 decades. This showed that there is a shortfall in the supply side of iodized salt and MIÕs interventions have focused on addressing this shortfall.
¤ The KIO3 subsidy scheme when effectively implemented and properly monitored, would act as an incentive to small scale iodized salt producers who would otherwise be selling non-iodized salt low cost in rural markets.
¤ A key observation was that several salt iodization units belonging to small/medium scale producers have been lying idle over the past few years due to poor maintenance and lack of essential spare machinery parts. These producers have continued their salt production but have been selling in open markets as non-iodized edible salt. MIÕs intervention in rehabilitation of these plants would serve as an incentive for these producers to iodize their product.
Plans for 2006:
51. The MI plans to
á Continue with and expand KIO3 subsidy scheme to 20 tons in 2006, enabling production of 400,000 tons of edible iodized salt and the potential reach of 114 million people.
á Effective utilization of salt extenders in the 4 salt producing states, to undertake rehabilitation of small scale salt iodization units and installation of new plants.
á Organize dissemination workshops in 4 states in collaboration with ICCIDD to advocate the measures undertaken by MI to promote USI in India.
á Provide maintenance support to TNSC & HSL iodized salt plants to enable continuous operation at steady output capacity.
á Implement targeted USI program in Rajasthan on behalf of a WFP-MI Joint Initiative.
For further information on MIÕs work in India, please contact Saraswati Bulusu sbulusu@micronutrient.org
52. Nepal has an u5MR of 82[4]; 33% of children under five are deficient in Vitamin A; total goiter rate is estimated to be 24%; anemia rates among pregnant women is 62% and for children under five it is 65%. VAD / IDD / IDA is considered high to average for the sub-region[5]. MIÕs highest priorities in this reporting year were to continue to ensure high vitamin A supplementation coverage, increase coverage for anemia programs and to explore ways in which to increase household use of iodize salt. The table below summarizes our projections and best estimates of what has been achieved as a result of contributions from MI[6].
53. Despite the political instability in Nepal, MIÕs efforts in assisting the government to develop an anemia plan of action resulted in it being finalized and approved by the Government of Nepal as their own document. In 2005 MI supported programs that reached nearly 4 million beneficiaries by providing vitamin A capsules and technical support. Coverage was also generated from the programs to intensify maternal supplementation, the low dose vitamin A project and wheat flour fortification initiative. In 2006 MI plans to intensify its current programs and embark on support to salt iodization. The total effective coverage generated is estimated to be 5.6 million mainly through VAS and wheat flour fortification.
VAS programs:
54. VAS for preschool children: The MI supports the VAS program in Nepal by providing capsules and technical inputs. The VAS program in Nepal targets children from 6 to 59 months through twice annual vitamin A campaigns. Nepal has consistently achieved high coverage (>85%) for the past few years. The coverage rates have been verified by national surveys every 4-5 years and by rapid coverage surveys conducted after each round. It is estimated that a total of 8,187 lives were saved due to two rounds of high coverage in 2005.
55. Low dose vitamin A supplementation for treatment of nightblind pregnant women: Nightblindness the most common manifestation of vitamin A deficiency and during pregnancy it is a significant indicator of the risk of death not only in pregnancy but also during delivery and postnatal period. In line with the government policy, MI supported - through UNICEF - a pilot project to treat nightblind pregnant women by supplementing low dose vitamin A capsules (25,000 IU). The Nepal Family Health Program (NFHP)- USAID provided support for the monitoring of the project activities. The pilot project, implemented in 3 districts, has been completed. According to the preliminary report, 81 % of the nightblind pregnant women who completed treatment were cured. As part of final evaluation process, a household census is ongoing to collect accurate information on the number of pregnancies and nightblind pregnant women and coverage of low dose vitamin A capsule treatment. A detailed report on performance of the program, recommendations with respect to effective delivery model, and a future expansion plan is expected by the end of February 2006.
VA fortification programs:
56. Vitamin A Stability Study: Edible oil has been considered to be one of the promising food vehicles for vitamin A fortification in Nepal. However both government and private sector have concerns about the stability of vitamin A during cooking. The MI therefore supported the Department of Food Technology and Quality Control, Ministry of Agriculture and Cooperatives in conducting a study to assess retention of vitamin A during storage and typical Nepali cooking. Vitamin A in fortified cooking oil packed in opaque HDPE pouch and jerry-can has been found to be quite stable. Similarly, during vitamin A retention in pan fried green vegetables was also reasonable. However, loss of vitamin A during a typical Nepali snack food (Sel) preparation with deep frying was tremendously high. Virtually no vitamin A was retained after the 5th batch of cooking of the snack food.
57. The Vitamin A stability study in Nepal has produced mixed results. It is obvious that further tests are required to confirm the results obtained from Nepal study. MI therefore plans to replicate the study at another laboratory (most probably in Canada). Based on these results, next steps towards vitamin A fortification of edible oil will be taken.
58. Wheat flour fortification: MI signed an agreement with Nepal Flour Mills Association in March 2005 to expand the voluntary fortification of wheat flour (Maida and Aata) with iron, folic acid and vitamin A. Consequently, all of the 20 roller mills in the country have signed a ÔLetter of InterestÕ for participating in the national scale wheat flour fortification program. At present five roller mills are fortifying their atta flour.
59. MI continued to work with a Pakistani microfeeder manufacturer to develop a microfeeder suitable for Nepalese roller mills. After a series of modifications on the design of the microfeeder based on a trial and error method, the company finally overcame almost all major limitations in November 2005. We also resolved some problems associated with fortified refined wheat flour (Maida). For this we conducted a series of sensory test of bakery products and instant noodles made up of wheat flour fortified with various forms of iron viz. elemental iron, ferrous sulphate, and ferrous fumarate. It has been recommended to use premix with ferrous fumarate or elemental iron. It is expected that national fortification program will commence by the end of May 2006.
Social Marketing of low-cost fortified complementary food:
60. In March 2005, MI signed an agreement with Population Services International (PSI) to implement the social marketing campaign for promotion of low-cost fortified blended complementary food. The target group of this program is children of 6-23 months old from low income families. We also formulated the composition of the product based on the latest scientific literature in this regard. As an implementing agent, PSI is at present developing the full product concept and testing BCC materials. They have also obtained the provisional approval from Child Health Division to implement the program. Particular care is being taken to work very closely with the Ministry of Health to ensure that the promotion of the low-cost fortified complementary food is well coordinated with messages that promote exclusive breastfeeding. It is expected that the social marketing campaign will be lunched by March 2006. MI will continue to work with Child Health Division of the Ministry of Health and PSI in monitoring and evaluation of the program.
Small Scale Fortification:
61. MI carried out a feasibility study in relation to small scale fortification in some rural parts of Lalitpur district in early 2005. The study has revealed that it would be socio-cultural as well as economically feasible to fortify cereal flours with vitamins and minerals at small scale mills such as water mills. Consequently, we developed a pilot fortification project and signed a grant agreement with a local NGO to implement the project in a village development committee of Lalitpur district. Trial fortification at one water mill has also been launched and it is expected that the pilot project will be implemented in full scale by May 2006. We are also planning to conduct an evaluation study of the pilot project and the baseline enumeration will be completed by March 2006. As this is a pilot/effectiveness project, the reach is quite low until the project scales up.
62. MI also hired a research and development company to develop appropriate fortification technology for cereal fortification at small scale chakki mills operated in rural areas. The prototype of the device has been developed and preliminary tests have indicated promising results. The next step in this project is to identify funding for scaling-up. The initiative has already been discussed with some donors and concept notes have been shared.
Intensification of Micronutrient Supplementation to Pregnant and Post-partum women:
63. In view of the success of the phase I of this program, we planned to expand the program in 36 districts in a three year time period. Accordingly, we supported the first year program in 12 districts. Out of 12 districts, the program has been implemented in 8 districts so far and activities in the remaining districts will be completed by March 2006. From phase 1, covering a total of 5 districts, this initiative reached 200,000 women.
64. MI also carried out a follow-up study in phase one districts to assess whether success of the program has still been sustained after 2 years of implementation of the program. The study revealed very encouraging results. Coverage of iron/folate supplementation increased to 85%. Based on the positive results, we aim to expand the program in 12 more districts in the coming year.
5-Year Plan of Action for control of anemia
65. MI continued to provide technical assistance to Child Health Division/Department of Health Services (MoH) in finalizing the comprehensive 5-year Plan of Action for controlling anemia among women and children in Nepal. The MoH has recently approved the Plan, costly US $10 million over five years. On request of Child Health Division, MI is providing support for publication and dissemination of the Plan. The Plan of Action is expectedly be launched nationally by March 2006. This will be an important tool to stimulate attention to addressing anemia comprehensively in Nepal.
Iodized salt:
66. National IDD status survey: To track the progress of universal salt iodization program- the sole strategy of HMG/Nepal for controlling IDD, MI supported a national IDD status survey in 2005. All the field work has been completed. Mainly two indicators are being assessed - salt iodine and urinary iodine. While salt samples were analyzed in a laboratory in Nepal, urinary iodine was analyzed in ICCIDD laboratory in New Delhi, India. Sub-samples of urine were also analyzed at a laboratory in Australia for cross verification purposes. MI aims to develop appropriate programs to deal with iodine deficiency in Nepal once the survey report is disseminated, which is expected to take place by May 2006.
Situation Analysis of cross-border movement of salt:
67. It has been realized that the terai (plain) areas lying along the highly-populated Nepal-India border are more vulnerable to IDD compared to hilly and mountainous areas. The main factor behind this situation is the easy movement of non-iodized and inadequately iodized salt from India to Nepal through open border areas along eastern, southern and western sides. Appropriate solutions to this problem are needed, as it is affecting a significant proportion of Nepalese as well as Indian populations. This is especially serious in Nepal due to the fact that although the terai constitutes only about 17 % of total land area of Nepal, it is home to almost half (48.4 %) the Nepalese population.
68. In response to a request from Child Health Division, Department of Health Services (MoH), MI is planning to conduct a situation analysis to assess the current status of cross-border salt movement along Nepal India border. Based on analysis findings, appropriate interventions will be developed and implemented to address the problem. The situation analysis will be completed by March 2006.
69. Based on research on the risk of inadequate zinc in the national food supply and national prevalence of childhood growth stunting, Nepal has been categorized as a country having moderate risk of zinc deficiency (IZiNCG, 2004). Children between 6 to 23 months are at an elevated risk of zinc deficiency. As mentioned in the section 7.2, MI is working with various partners to introduce a social marketing campaign for promotion of low cost fortified blended complementary food targeting children of 6-23 months. In order to address zinc deficiency among this vulnerable subgroup of children, the complementary food will be fortified with zinc along with 10 other micronutrients. The fortified complementary food is aimed to provide at least 67% of daily requirement of zinc and is expected to benefit the children in terms of improved growth and reduced incidence of diarrhea.
For further information on MIÕs work in Nepal, please contact Macha Raja Maharjan
70. Pakistan has an u5MR of 103[7]; 35% of children under five are deficient in Vitamin A; total goiter rate is 38%; iron deficiency anemia rates among pregnant women is 59% and children under five is 56%. MIÕs highest priorities in this reporting year were to maintain high coverage rates of VAS with NIDs, pilot a post-NIDs Vitamin A supplementation project and initiate programs to increase consumption of iodized salt. Also, MI assisted the government as much as possible in ensuring vitamin A was distributed to children in the earthquake hit areas. Support to national actions to reduce and control VMD
71. During the reporting period, MI assisted the Nutrition Wing – Ministry of Health in developing the ÒNational Plan of Action (NPA) for the Control of Micronutrient Malnutrition in PakistanÓ. The document has been published (October 2005) and was formally launched on 28 February 2006. The NPA is part of the overall National Nutrition Strategic Plan formulated by the Nutrition Wing – MoH in active collaboration with DFID, UNICEF, USAID and MI. The Nutrition Wing has already started using the NPA and has put in supplementation and fortification activities suggested in the NPA in their PC-1 (Pakistan governmentÕs official planning and budgeting document). Inclusion of these activities in the PC-1 is expected to lead to further investment by the Government of Pakistan in micronutrient programs. It is important to note that Vitamin A supplementation has already been included in two separate PC-1s, which is a good sign for the sustainability of the national VAS campaigns in Pakistan.
Response to earthquake:
72. The MI promptly responded to MoH request for supervision and coordination of the Òmeasles with VA supplementation campaignÓ of the MoH in quake hit areas of Azad Jammu and Kashmir (AJK) by deputing its Program Coordinator for Wheat Flour Fortification Program AJK to coordinate and supervise the campaign. During this campaign about 197,000 children were provided VA capsules in three districts of AJK. Similarly the MI also assisted the North West Frontier Province (NWFP) government and other agencies in various activities including VAS in the earth quake affected areas of NWFP. Approximately 0.238 million under five children were provided vitamin A supplementation.
73. The MI is currently assisting the various active partners (UNICEF, WHO, WFP, MoH and partner NGOs) in the Food & Nutrition sector in designing and implementing low cost and effective solutions for fighting malnutrition in the earthquake affected areas of Azad Jammu Kashmir and North West Frontier Province in Pakistan. Interventions may include multi-micronutrient Sprinkles for children (agreed upon intervention of choice is Home-based Multi-micronutrient Fortificant - HMF), wheat flour fortification for the general population and iodized oil capsules (Lipidol Capsules) for women and children.
74. In 2005 MI reached a total of 21.8 million beneficiaries. In 2006, MI will continue to focus on VAS and USI. MI will work with the government to review the AJK wheat flour fortification project, with a view of using the funds to provide emergency support to earthquake-affected people.
75. VAS programs: VAS activities were carried out with NIDs throughout the country. All the children between 6-59 month were targeted for VAS. The coverage obtained was above 95%. MI continued to provide technical support and capsules were provided by the MI via UNICEF. In 2005 a total of 26.7 million children were reached with two doses of vitamin A. It is estimated that 63,099 lives were saved in 2005 due to two high rounds of coverage.
76. A post-NIDs strategy for VAS was piloted through UNICEF in 14 districts of three provinces to see the efficacy of linking VAS to routine immunization. For this activity 2 months (October 2005 and April 2006) were selected as Òvitamin A monthsÓ. In October 2005, in the piloted districts, VAS was provided through Lady Health Workers, vaccinators and remaining uncovered areas were covered through child health weeks. The MI has recruited five Program Coordinators for VAS at provincial/regional level. These coordinators provided technical assistance on VAS to the provinces/regions and districts, established MI committees in three provinces and a region, provided support to the MI-assisted UNICEF pilot for VAS in a post NID era in 14 districts, assisted in improving VAC supply and distribution system and quality of training at all levels, involved in other activities of the MoH targeted to improved VAS coverage including emergency work in the earthquake hit districts of Pakistan and enabled to position MI at the regional and provincial level.
77. MI provided support to the Federal EPI cell in their Òmeasles with VA supplementation campaignÓ in the earthquake hit areas districts of AJK and NWFP. During this campaign 0.435 million children were provided with VAS.
78. In 2006 MI will continue to provide technical support to the VAS program. Capsules will continue to be required for delivery with NIDs. A report on the results of the post-NIDs pilot project is expected in early 2006.
Iron fortified foods:
79. The MI assisted the Ministry of Health (MoH) in a successful bid to GAIN for assistance to the National Flour Fortification Program with the goal of tackling the enormous burden of anemia in the country. Under this program the formal sector of the flour milling industry (that caters to almost 55% of the population - approx. 83 million) would achieve universal flour fortification over a period of 5 years. The MI assisted the Government of Pakistan in signing the grant agreement with GAIN. MI also assisted the Technical Sub-Committee in selecting the pre-mix for the Program. The Government of Pakistan has received the first installment of funds from GAIN and is ready to start program implementation. The MI will play a leading role in the execution of this program; implementation is expected to start in early 2006.
80. On the request of the Health Department of the State of Azad Jammu and Kashmir and the Federal Ministry of Health, Pakistan, the MI provided technical assistance to the State of Azad Jammu and Kashmir for launching a Universal Flour Fortification project in Kashmir. The MI and Government of the State of Azad Jammu & Kashmir signed an MoU on 25th August 2005. The MI hired a full time Project Coordinator for this Project and is set to be the lead implementing agency for carrying out various activities proposed under this project. However due to the earthquake MI is currently discussing the fate of this project with the government. It is possible that the funds that had been set aside for this project will be used to provide emergency assistance in the earthquake-affected areas.
81. The MI is providing technical assistance to The National Program for Family Planning and Primary Health Care (FP&PHC) of the MoH to develop a proposal for the introduction of multi-micronutrients sprinkles for complementary foods for children 6 to 24 months.
82. For the first time in Pakistan, Greenstar Social Marketing Pakistan (Guarantee) Limited has launched a pilot project for the social marketing of Home-based Multi-micronutrient Fortificant (HMF) for children under 2 in Karachi and Hyderabad. MI is co-financing this project and is providing the technical assistance. MI has helped a local pharmaceutical firm produce the HMF in Pakistan.
83. MI provided support to the Department of Paediatrics, The Aga Khan University and WFP for the bio-chemical assessment component of the project for Nutrition Supplement Acceptability Pilot for the Pregnant and Nursing Mothers and their infants in rural Sindh. The pilot project will study the impact of fortified blended food on improving the micronutrient status of expectant and nursing mothers and their infants in Pakistan.
Iodized salt:
84. More than half of the population in Pakistan is still at risk of IDD. All the previous attempts (except some pilots) at salt iodization had no encouraging results in reducing brain damage among the 2.1 million newborns and increasing the production and utilization of adequately iodized salt above 17%. In 2005 MI placed a full time National Program Officer in the Ministry of Health (Nutrition Division) who is assisting the MoH in revamping the National IDD Control program. Unfortunately due to the earthquake, the new work on this was delayed by a few months.
85. As a first step, a situation analysis and inventory of the salt sector has been completed. There are 1172 salt producing/processing units in the country with a total annual production of 1.33 million tons salt out of which 93,500 tons is produced for human consumption. Only 9% of the total salt produced is iodised. The salt processors are mainly (67%) small scale producers who are deficient in iodization facilities and capabilities. The emphasis currently and in the coming year for the MI is to build capacity of the salt sector through the provision of equipment, technical assistance and where required, potassium iodate.
86. Based on the findings of the situational analysis of the salt sector in the country a comprehensive work plan has been prepared to achieve a target of 30% iodization in 20 pilot districts through coordinated efforts of MoH, UNICEF and the salt sector representatives. The main focus will be on the capacity building of the salt producing sector with logistic arrangement for the iodization of salt. This includes provision of Potassium Iodate (KIO3), feeders, dry mixers, installation of salt iodization plants, standard printing blocks etc. These efforts will further be augmented with training exercises, devising monitoring and reporting systems, quality control measures and promulgation and enforcement of legislation.
87. This work is being closely coordinated with the World Bank, as one of the conditions of the BankÕs main credit to Pakistan is that they achieve 30% coverage of iodized salt in the same 20 districts. This is a good example of where the World Bank and MI can work together at country level, and where the Bank takes the lead in setting policy targets with the Government and the MI works with the Government to support them in achieving the goals.
88. There is no proper procurement and distribution system in the country for potassium iodate (KIO3). The MI has hired a consultant to work on the economic analysis of KIO3 including the assessment of a shift from dependency on donors towards a market driven phenomenon with a gradual withdrawal of subsidy during the course of next five years.
89. MI and WFP will be working together on the elimination of iodine deficiency disorders through USI in 29 districts of North West Frontier Province (NWFP), Azad Jammu & Kashmir (AJK) and Federally Administered Northern Areas (FANA). The estimated beneficiary population is 22,800,000. The project aims to increase the use of iodized salt from 17% to 60% of households in the targeted population in two years as well as putting in place a sustainable system to procure annual requirements of potassium iodate for the target areas. In 2006 MI plans to reach approximately 44 million people with iodized salt.
For further information on MIÕs work in Pakistan, please contact Noor Khan
[3] VMD global progress report: MI/UNICEF (2004)
[6] Reach (in thousands) is the largest number of people in the project target groups who benefited from the project during the reporting year. APC (in thousands) is the # of additional person years of coverage achieved by each project