From Research to Policy to Programme: Success Story of Seven State Iodine Deficiency Disorders (IDD) Survey in India

Iodine Deficiency Disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. In India the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. Of these, an estimated 350 million people are at higher risk of IDDs as they consume salt with inadequate iodine. Every year nine million pregnant women and eight million newborns are at risk of IDD in India.On September 13, 2000, the Government of India lifted the ban at the national level on the sale of non-iodized salt (India Gazette 2000). Scientists, civil society, international agencies and other stakeholders joined ranks to fight against this retrograde step by the government of India. The four pronged approach to fight the removal of ban on non- iodized salt comprised of writing advocacy documents, meeting with stakeholders, media campaign and tracking of Universal Salt Iodization (USI) in states by state iodine status surveys.But effective advocacy and media campaign were hampered by lack of scientific data substantiating the magnitude of Iodine Deficiency disorders (IDD) in India. To address this lacuna, state level Iodine status surveys were planned in seven states of India and were executed over next five years in collaboration with various national and international stakeholders.State level IDD surveys were carried out in seven states (Kerala, Tamil Nadu, Orissa, Rajasthan, Bihar, Goa and Jharkhand) from 2000 to 2006 by International Council for Control of Iodine Deficiency Disorders (ICCIDD) in collaboration with state medical colleges, Micronutrient Initiative (MI) and UNICEF. The surveys were carried as per the recommended guidelines of WHO/UNICEF/ICCIDD and used 30 cluster into 40 children sampling methodology. Children in the age group of 6-12 years, women in the household, retail shop keepers and other community stakeholders constituted the study population. All three indicators viz. Total Goiter Rate (TGR), Urinary Iodine (UI) concentration and iodine content of salt (household and retail shop) were studied. TGR ranged from 0.9% in Jharkhand to 14.7% in Goa. The median urinary iodine excretion ranged from 76 µg/L in Goa to 173.2 µg/L in Jharkhand. The household level consumption of adequately iodized salt ( ≥ 15 ppm) ranged from 18.2% in Tamil Nadu to 91.9% in Goa. These state level IDD surveys are the only sub-national (state) level IDD surveys in India where all three indicators viz. iodized salt coverage, urinary iodine and TGR were assessed concurrently.These surveys provided valuable reliable scientific data to back up the need of urgency to re-instate the ban and aided in convincing wider scientific community and policy makers regarding the need for the same. These surveys also aided in capacity building at state level which will provide necessary impetus to sustain USI. The ban on sale of non-iodized salt was finally re-instated in May, 2005.Purpose of the study : To understand the complex policy environment in which National Health Programmes in India are operating.Basic Procedures : A case study approach applying the criteria of policy formulation and policy implementation to National Iodine Deficiency Disorders Control Programme (NIDDCP).Main Findings : The major limiting factor in the implementation of NIDDCP was that the community perceptions about IDD and iodized salt and their interests and beliefs (Values) were not explicitly considered as part of the implementation process. Addressing the values through sustained advocacy, development of partnerships among stakeholders, supply and demand side interventions and more research based on the programme needs helped in achieving sustainability in elimination of IDD.Conclusion : In formulating National Health Programmes in a policy environment, scientific inputs, political will and institutional structure for decision making are necessary but not sufficient. Pro-active recognition values of key stakeholders, continuous and dynamic generation of scientific information and development of partnerships are critical for sustainability of the National Health Programmes.