Reaching the Poor with Adequately Iodized Salt through the Supplementary Nutrition Programme and Midday Meal Scheme in Madhya Pradesh, India.

Objectives: Adequately iodized salt needs to be made accessible to the most marginalized. Madhya Pradesh, a state in central India, is home to a substantial proportion of India's poor. In 2009, the coverage of adequately iodized salt in the state was nearly 90% among the richest households, but only about 50% among the poorest. Methods: In an effort to provide adequately iodized salt to the most vulnerable, in 2009 Madhya Pradesh launched a state-wide initiative to ensure the use of iodized salt in two national flagship nutrition programmes: the Supplementary Nutrition Programme of the Integrated Child Development Services and the Midday Meal Scheme. Programme staff members were taught how to correctly store salt and monitor its iodine content. Field monitors assessed the iodine content of the salt in the common kitchens of participating schools and anganwadi centers monthly. Results: Two hot meals prepared with adequately iodized salt were served daily for more than 21 days per month to approximately 89% of the 12,113,584 children aged 3-6 years enrolled in anganwadi centers (June 2011-March 2012). One meal on school days was served to 78% of 5,751,979 primary-school children and to 79% of 2,704,692 secondary school children (April 2011- March 2012). Most of the kitchens visited in 2010 (79%) and 2011 (83%) were consistently using adequately iodized salt to prepare hot meals. Conclusions: India has successful large-scale social safety net programmes targeting the most deprived population. Both national and state-level policies should mainstream the use of adequately iodized salt in these programmes.

Reaching the Poor with Iodized Salt through the Public Distribution System: Experience from Andhra Pradesh, India.

Objectives: The state of Andhra Pradesh (AP) is home to a substantial proportion of India's poor with 51% of the state's population living below the national poverty line. In 2009, access to adequately iodized salt in AP was nearly 90% among the richest households, but 44% among the poorest. This presentation documents the large scale effort made by the state government to improve access to adequately iodized salt by the poorest households. Methods: AP's situation led UNICEF and other partners to request that the state government accelerate efforts to make iodized salt available to the poorest households - and potentially the most vulnerable to iodine deficiency - through the Public Distribution System (PDS), India's food security safety-net for the poor. Results: Subsequently, in 2012 the state government made a decision to ensure the distribution of iodized salt through the PDS as part of a ration comprising nine subsidized food items. The ration - referred to as Amma Hastham (i.e. mother's hand) - is sold through a network of 44,000 PDS' fair price shops. It comprises wheat flour, whole wheat grains, lentils, sugar, oil, tamarind, turmeric, chili powder and iodized salt. Iodized salt is made available at subsidized cost of INR5 (USD 0.016) per kg per month. Conclusions: Currently 23.2 million families with an average size of 5 members are benefitting from this initiative, launched by the State Chief Minister with extensive media coverage for public sensitization and demand generation. Efforts are underway to ensure proper monitoring of the quality of salt and its iodine content.

Is Vitamin A Supplementation Programme Reaching the Most Vulnerable Children in India? New Evidence from Odisha.

Objectives: Surveys in 2002-05 indicated that the prevalence of severe forms of vitamin A deficiency in India was three-fold higher among children from schedule tribe (ST) households than among non-tribal children. Scheduled tribes constitute about 24% of the total population of the state of Odisha. This presentation documents the performance of Odisha's vitamin A supplementation (VAS) programme in reaching the districts and blocks with a higher concentration of tribal population. Methods: A sub-group, disaggregated analysis of VAS coverage was conducted. Districts and blocks were divided into five quintiles with the highest quintile comprising the 20% of districts and blocks with the highest concentration of ST households. Results: The full VAS coverage in Odisha increased from 61% in 2006 to 97% in 2011. Overall, full VAS coverage figures increased in all quintiles between 2006 and 2011. However, the most significant increases were recorded in the quintiles with the lowest ST concentration, while the increases in the highest quintiles were more modest. Since 2006, the districts and blocks with the highest proportion of ST children consistently had the lowest full VAS coverage. The estimated number of non-fully covered children decreased from 1.2 million in 2006 to 0.1 million in 2011, but ST children still represent about 32.3% of those who are not fully-covered.

Improving the Availability of Adequately Iodized Salt by Mobilizing the Network of Salt Traders in Uttar Pradesh, India.

Objectives: Uttar Pradesh (UP) is a non-salt producing state in India. Most of the salt is imported and traded in 18 of the 75 districts in the state. In 2009, the household coverage of adequately iodized salt in UP was 43%. This presentation features the important initiative taken by the state government with support by UNICEF to increase the availability of adequately iodized salt by mobilizing the network of salt wholesalers and retailers in UP. Methods: A total of 204 wholesalers and retailers were mapped across the 18 salt unloading districts. Four titration laboratories in the state medical colleges were revitalized. Salt samples were collected from shops and storage points on a monthly basis and sent to the laboratories to test the samples' iodine content. Reports on the iodization adequacy of salt were issued, shared with the wholesalers and retailers and used to monitor the iodization quality of salt. Monthly dialogue with salt wholesalers and retailers was carried out to sensitize and motivate them to procure and sell only adequately iodized salt. The salt testing results were also used by the Salt Department and the Department of Food and Drug Administration to take punitive actions against manufacturers producing inadequately iodized salt. Results: The availability of non-iodized salt decreased by 2.5% and availability of adequately iodized salt increased by 10% over a one-year period. Conclusions: Mapping, sensitization and using a combination of punitive and non punitive approach with the wholesalers and retailers proves to be an effective strategy to ensure adequate availability of appropriately iodized salt.

Towards an Anemia-Free West Bengal: Convergent Policies and Collective Action.

Objectives: West Bengal - India's most densely populated state - is home to 8.3 million adolescent girls. Surveys indicate that 62 percent of adolescent girls were anemic, despite several sectoral programmes in place. To address this situation, the Government of West Bengal launched in 2012 Anemia Free West Bengal strategy convening all stakeholders, integrating flagship programmes and introducing new schemes as needed. Methods: Six sectoral Departments that were implementing programmes focusing on adolescent girls were brought together under the leadership of State Chief Minister to convergently deliver interventions that includes: 1) Food supplements fortified with nine essential micronutrients; 2) weekly iron and folic acid supplementation; 3) Biannual deworming; 4) A new conditional cash transfer scheme to promote secondary education and prevent child marriage; 5) A state-wide mass and mid-media communication campaign; and 6) Partnerships for social mobilization at community and household level. Programme convergence included formation of a state planning and monitoring committee, joint training of staff, pooling of resources as feasible, common reporting using standardized tools using dis-aggregation of reporting data by social group. Results: By mid-2013, all monthly inter-sectoral progress review meetings had been held as planned, three of the six departments had pooled budgets to support the strategy, and about 2 million adolescent girls were already receiving iron and folic acid supplementation weekly, deworming bi-annually, fortified food supplements, and/or cash transfers. Conclusions: The better practices from W. Bengal experience are critical know-hows on building political commitment and programme convergence on programming for adolescent girls through a common vision.

Innovations in Reaching Out to the Most Vulnerable Population with Vitamin a Supplementation in Bihar, India.

Objectives: The state of Bihar historically has reported a high prevalence of vitamin A deficiency. Yet, in 2006 only 26% of preschool children were receiving vitamin A supplements (VAS) biannually. This presentation reviews the innovative strategy implemented by the Government of Bihar with UNICEF support to improve VAS coverage by reaching out to all children, including the most vulnerable in the hard-to-reach communities. Methods: More than 80,000 anganwadi centres and 11,000 primary health centres have been mapped out to become the core distribution sites of the biannual VAS rounds. Every primary health center is required to map all the underserved communities in their catchment area. The underserved and hard-to-reach communities are clustered and 3,500 temporary sites have been created to deliver VAS. Results: The village-based frontline workers and volunteers have been trained to administer VAS to children and counsel mothers on how to improve the vitamin A content of their children's diet. Additionally, left-behind communities are mapped annually and reached out through additional sites. Intensive communication and mobilization drives are undertaken at all levels to raise awareness about the benefits of VAS and mobilize communities. As a result, the full VAS coverage increased to 96% in 2012. Conclusions: The Government of Bihar has demonstrated that it is feasible to implement a successful and inclusive VAS programme in India, that reaches all children if efforts are made to understand who the most vulnerable children are and where they live, and if political decisions are made to assign the required human and programme resources.

Girls' Collectives Address Adolescents' Anemia and Social Norms in Socially-excluded Tea Estates in India: A Public-private Partnership in Assam.

Objectives: To generate evidence on engaging girls' collectives to address anemia and social norms in self-contained, privately-managed tea plantations in India. Methods: In 2006, UNICEF India partnered with a federation of tea companies in Assam's Dibrugarh district, and Twinning Corporate Social Responsibility to establish 158 girls' collectives across 117 of 273 tea gardens. These collectives meet weekly to discuss and address social issues such as child marriage, child labor, school dropout, and life skills. In 2012, supervised weekly iron folic acid (IFA) supplementation, biannual deworming and nutrition education were weaved in these peer interactions and implemented in 15 tea estates through 45 girls' collectives comprising 7097 adolescent girls, with the objective to address anemia. Visual aids, recipe demonstrations, and home gardening were used to make sessions interesting. Government positioned adequate supplies at tea estate hospitals/outposts. Two peer monitors per tea estate supervised the activities of the collectives. The follow up of this cohort included a baseline (2011) and an end line (2013) survey. Results: Compliance with weekly IFA supplementation (4 tablets per month) increased from 25% (2012) to 82% (2013). Home gardens were introduced in 1,002 homes and 55 community patches. Provisional end line data shows a 1.25 g/dl improvement in mean hemoglobin levels (9.77 to 11.2 g/dl). There is also evidence of increased girls' re-enrollment in high school and a reduction in the proportion of child marriages. Conclusions: Lessons from this public-private partnership can be adapted to similar programming environments that aim at reaching out to adolescent girls with anemia control interventions.

India's Adolescent Anemia Control Programme: Ten Make-or-break Elements for Sustaining Success.

Objectives: In India, 56% of adolescent girls are anemic. In response to this situation and building on 13 years of evidence-generation using a knowledge-centred framework (evidence, innovation, evaluation and replication), India's adolescent girls anemia control programme was universalized in 2013 covering 130 million adolescents. Implemented jointly by Ministries - Health, Education and Women and Child Development, services delivered by the programme include: 1) weekly iron and folic acid supplementation; 2) bi-annual deworming; and 3) nutrition counselling. UNICEF is technically supporting the government in roll out of the programme in 14 Indian states that house 88 percent of total adolescent girls in India. Methods: Using information emanating from programme reports analyses, structured interviews with state programme implementors and a national consultation, this presentation highlights ten make-or-break elements to address the most important challenges encountered in the universal rollout of the programme. Results: Ten make-or-break elements are: 1) political will along with well-defined inter-ministerial convergence and accountability mechanisms; 2) solving procurement challenges and continued supply monitoring; 3) instituting emergency response mechanisms (teams, helplines, standardized tools) for managing undesirable events; 4) sustained media engagement; 5) ensuring technical human resource support to state governments where capacity is sub-optimal; 6) devising a supplementation strategy during school vacations; 7) monitoring and evaluating the programme implementation independently through civil society/academia; 8) associating celebrities, parliamentarians and religious/peer leaders to mass communication campaigns; 9) ensuring functional review mechanisms; and 10) specific strategies to reach the unreached. Conclusions: All the ten make-or-break elements are critical for ensuring success of an universal adolescent anemia control programme.

Accelerating Progress to Universal Salt Iodization in India Achievements, Challenges, and Future Actions.

Objectives: India was one of the first countries to introduce salt iodization. This presentation reviews the national efforts towards universal salt iodization (USI) in India, documents achievements and progress, and highlights key challenges in programme implementation. Methods: The Salt Department of the Government of India and its development partners have made concerted efforts to improve availability, access and use of adequately iodized salt. Results: National and state level advocacy meetings were carried out to ensure high political commitment and prioritization of the USI programme. The National Coalition for Sustained Iodine Intake was launched to improve the overall programme management and coordination. The technical capacity of salt producers was enhanced and salt wholesalers and retailers were mapped, sensitized and equipped with tools and skills to procure only adequately iodized salt. A state-of-the-art management information system was launched to improve the efficiency in monitoring the flow of iodized salt. In addition, awareness and communication activities were scaled up to generate demand for iodized salt. As a result, the national household coverage of adequately iodized salt increased from 51% in 2005 to 71% in 2009. However, data indicate a clear urban-rural and rich-poor differential, leaving some of the most disadvantaged populations vulnerable to iodine deficiency. Conclusions: An evidence-based, well-defined strategy will be necessary to reach the last 30% of households, which are are likely to be least accessible and most socio-economically vulnerable. Both national and state level policies should mainstream the use of adequately iodized salt in feeding programmes for the benefit of all.

Scaling Up Vitamin a Supplementation in India: Much Progress, Some Challenges.

Objectives: Preventive vitamin A supplementation (VAS) is an proven child survival intervention. Since 2006, the National and State Governments of India supported by UNICEF and other development partners have made combined efforts to strengthen the implementation of biannual VAS rounds. This presentation reviews the VAS programme in India, aiming to characterize the coverage at national and state levels since 2006, and identify better practices, enabling factors, and bottlenecks. Methods: We carried out a thorough analysis of the VAS programme coverage data, a review of relevant literature, field observations and interviews with key stakeholders. Results: The national full VAS coverage increased from 33% in 2006 to 63% in 2012, with a record 61 million children protected in 2012. However, the programme is implemented in different ways in different states, with variable degrees of success. The coverage has remained high (≥80%) in Bihar and Odisha, while it underwent significant fluctuations in Karnataka and Tamil Nadu. A few states have had persistently low coverage (<50%). Notably, programme coverage has significantly increased in the districts with the highest concentration of poor households, scheduled caste, and scheduled tribe populations. The critical success factors for the VAS programme include strong leadership of the government, a stable procurement mechanism of VAS, effective micro-planning, and flexible dosing mechanisms to cover hard-to-reach areas. Conclusions: Despite the remarkable progress in improving the coverage and equity of the VAS programme, a large number of Indian children - potentially the most vulnerable and undoubtedly the hardest-to-reach - are not yet benefitting from this life saving intervention.

Scaling up Weekly Iron and Folic Acid Supplementation in Jharkhand, India Minimizing Challenges, Maximizing Opportunities.

Objectives: Jharkhand is a predominantly tribal Indian state. Home to 3.5 million adolescent girls, two-thirds of Jharkhand's adolescent girls were reported to be anaemic. In 2000, the Government of Jharkhand launched the Adolescent Girls Anemia Control Programme (AGACP) in five of its 24 districts with technical support by UNICEF. This presentation summarizes a decade of experience in scaling up Jharkhand's AGACP. Methods: In its initial phase, the programme covered around 250,000 school-going adolescent girls in 2800 schools. The intervention included weekly iron and folic acid (IFA) supplementation, bi-annual deworming, and nutrition counselling. The second phase was launched in 2009 to cover two million adolescent girls. During this phase the programme faced important challenges due to a break-down in the supply chain of IFA supplements and deworming tablets. However, weekly nutrition counselling sessions continued. The third phase of the programme was inaugurated in 2012 with the advent of the National Weekly Iron and Folic Acid Supplementation (WIFS) programme implemented in a convergent manner by the Departments of Health and Family Welfare, Women and Child Development, and Education. Results: The programme has been universalized across all 24 districts, by the state government. Currently, the programme covers 3 million adolescents. Conclusions: Approaches used for stabilizing the programme are valuable lessons (do's and dont's) in piloting, stabilizing and scaling up a large scale programme for the control of anaemia in adolescent girls in resource-constrained settings.