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.

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.

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.

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.