Population 1

Population:  153.578 millions
Population annual growth rate:   2.5%
Population < 18 years:  73,711 thousands; <5 yrs: 23,528 thousands
Crude birth rate:   36 per 1000
Life expectancy at birth:  61 years

Current Iodine Nutrition Situation

Total goiter rate in 1993 was 84.9%.

Median urinary iodine concentration (1993) was 16 µg/l with 90.4% of population had UIC<100 µg/L .

Household consumed adequately iodized salt 1 : 17 % (1995)

Salt Situation Analysis

Production 3

There are close to 600 primarily small-scale, private sector salt processors in Pakistan who crush and grind rock salt using manual labor and technology that has changed little for centuries.

Universal Salt Iodization Program

Information, Education, C ommunication (IE C ) Activities

UNICEF assisted designing a social marketing program in the highly endemic northern regions of Pakistan. Based on the success of this intervention, UNICEF subsequently expanded the project by contracting a local NGO partner, Social Marketing Pakistan (SMP), to implement the project on a national scale. In consultation with the Government of Pakistan and with continuing support and funding from UNICEF and the Canadian International Development Agency (CIDA), the Pakistan Iodized Salt Project works with the salt industry to ensure a sustainable supply of iodized salt while simultaneously creating demand among consumers.

As the supply of iodized salt hits the market, the demand creation campaign ensures that consumers choose iodized salt instead of non-iodized salt. Central to the marketing campaign was the development of the "Hand & Pot" logo, which has become the universal symbol for iodized salt in Pakistan. The demand creation campaign makes intensive use of mass media such as television and radio. The campaign has made the "Hand & Pot" logo a positive image, emphasizing the healthy family, rather than the negative aspects of IDD. In addition to mass media, a range of other communications channels are used to reach a variety of target audiences: salt retailers, doctors, teachers and volunteers in remote villages.

Figure 1. Logo for Iodized Salt in Pakistan

Legislation 2

Legislation on USI and national IDD control does not exist. Only two provincial governments have made iodization of all edible salt compulsory. The Federal Government is not having prescribed iodization levels on a nation-wide basis. As this has not been done, each Provincial government and each iodised salt producer has been adopting different levels of Iodine in salt. Though successive governments in Pakistan have voiced their anxiety over the extensive prevalence of IDD in the country and have expressed their willingness to take steps to eradicate the scourge, enough has not been done.

Program Monitoring and Evaluation

The first national country wide salt sector survey is currently on going. Salt survey is being carried out by the Micronutrient Initiative Pakistan.

Key Lessons Learned

• It is essential simultaneously to stimulate the demand for, and supply of, iodized salt. Campaigns in other countries which have sought only to raise awareness of IDD or only to increase the supply of iodized salt have rarely succeeded in reducing IDD significantly.

• Convincing private sector salt processors to invest their own funds makes the program effective and sustainable. A salt processor who has purchased mixing equipment, packaging and other items is far more likely to iodize his salt, to iodize correctly and consistently, and to continue to iodize, than a processor who has simply received equipment and materials free of charge via a government or donor subsidy.
• Legislation requiring that all salt be iodized, while important, has been ineffective on its own in countries where enforcement is difficult. Rather, legislation should accompany programs, such as the Pakistan program, which work with the private sector.

• International donors and governments are often not structured to work directly with the private sector. Nonprofit social marketing organizations, like PSI and SMP, provide the critical bridge between public and private sector.

Challenges and Constraints

Constraints include negative propaganda, the availability of non-iodized salt in the market, lack of interest and motivation among salt producers due to low demand and cost implications, and low enforcement of the national and provincial legislation. 4

•  Most of the salt processors, especially the small scale producers lack equipment, technical know-how and means for purchasing KIO3 and recovering the cost from consumers due to their market size.

•  In two of most populous provinces of Pakistan (75 % of country population), salt iodisation legislation is not in place.

•  In the provinces having legislation, the legislation is not backed by effective enforcement & monitoring consumption of iodised salt.

•  Integration of IDD control & USI program is not being properly & adequately treated as priority subject within the health services delivery.

•  Consumer awareness and demand for iodised salt is still not up to the mark which is some how or the other backed by rumours and fallacies.

•  In absence of a drastic policy shift it would be difficult to achieve the nutritional targets set under Government's Mid Term Development Framework for 2005-10 i.e., raising the household consumption of iodized salt to 50% in 2010.

Future Plans for Sustained IDD Elimination

A national strategic Plan has been developed and approved by the Government of Pakistan early this year. A five year phased out national action plan, 2005-10 was prepared in three phases. Ministry of Health, UNICEF, MI and Salt sector have been in closed coordination and some progresses have been made:

•  UNICEF continues providing KIO3 (until arrangements of importation - which is currently being developed - is established)

•  Private sector involvement in importation of KIO3, its distribution and proper utilization will be entrusted to some motivated and interested party such as HUB PAK salt industry.

•  Provincial Health Department especially those of Punjab and Sindh have been involved in promulgation of USI legislation and quality control. 

•  A good move in North-West Frontier Province (NWFP) is the establishment of Association of Salt Industry has been established in NWFP and they will be involved in the storage and distribution of KIO3 and regulation of salt processing units. 

•  A National Coalition on IDD control and USI is currently being formalized.

References:

•  UNICEF. The State of the World's Children. 2005

•  Moorthy D. and Pandav C.S. Reports from the Regions and the Countries by ICCIDD Regional Coordinators for India in Towards the Global Elimination of Brain Damage Due to Iodine Deficiency. Oxford University Press, 2004.

•  IDD Newsletter 21(1):10, February 2005.

•  I DD Newsletter 18(2):25, May 2002

•  MI Pakistan. Management of IDD Control Program in Pakistan. 2005.

•  http://www.psi.org/resources/pubs/salt.html