The Iodine Deficiency Elimination Program in Moldova

The USAID Micronutrient Program

An International Workshop on Monitoring IDD/USI program

Held in Dushanbe, Tajikistan August 1-3, 2005

Trip Report July 29-Aug 6, 2005

Draft: Robin Houston Phillip Makhamula USAID/MOST

Arnold Timmer John Egbuta UNICEF/Regional Office 8/18/05

2 Introduction

Tajikistan, like most countries in the region, has documented iodine deficiency, and has responded with the establishment of a mandatory salt iodization program. Like other countries of the Former Soviet Union, the previous salt production, iodization and distribution patterns changed dramatically, allowing for a likely worsening of the IDD situation. The recent National Nutrition Survey (2004) confirms continued iodine deficiency, and low household use of adequately iodized salt currently at 28%.

A number of regulations and food inspection mechanisms have been established, and these include mechanisms for testing salt at different levels. In addition, some attention has been given to the major salt producers, and ensuring good quality of the iodized salt produced. There is also ongoing monitoring of goiter among school children, providing both the number of goiters and the estimated prevalence.

The IDD elimination efforts is now facing specific challenges that can partly be addressed through an effective monitoring system: 1. Iodized salt production capacity exceeds estimated national requirements and conflicts with the national survey data of low use of adequately iodized salt (28%). An acceptable explanation for this discrepancy has not been found. 2. A large number of small salt producers concentrated in Khatlon Oblast do not produce iodized salt. There is currently no solution to address this source of non- compliance, which has been estimated to contribute as much as 20% of total edible salt consumption. 3. Reportedly, technical salt appears in the retail market for edible consumption purposes, and there are reports of counterfeited salt (non-iodized salt packaged as iodized salt) also in the market. Counterfeiting misleads consumers, and availability of both decreases the proportion of households using iodized salt. Current enforcement procedures have not yet addressed this weakness in the salt iodization programme. Close monitoring, special studies and punitive actions are required to correct this.

In spite of existing monitoring mechanisms, an overall integrated monitoring system that provides programmatic guidance particularly for the above mentioned challenges does not exist. Such system would permit identification and close examination of problem areas, and clear answers to some remaining questions about iodized salt quality, availability and use. Purpose

The purpose of this visit was to assist the government with a monitoring workshop designed to strengthen monitoring activities for the IDD/USI program in Tajikistan. The workshop was designed to involve representatives from all stakeholders, including the MOH, the bureau of standards, sanitary inspectors, salt producers, academic institutions, laboratory services, and both central and district/oblast levels. The workshop was participatory, allowing small group discussion on different levels of monitoring from

3 production/importation to consumption and impact. Full group discussion following these sessions allowed debate on areas of concern and responsibility for different monitoring activities.

The specific objectives and goals for the workshop were:

 To review existing monitoring activities for the IDD program, and refine these in the development of an integrated monitoring strategy and work plan to guide program activities  To provide a forum for representatives from different ministries, organizations and the private sector to review the current IDD situation, identify areas of concern, and develop a strategy to address these concerns  To review the current and pending regulatory environment for iodized salt and other potentially fortified products, and clarify the different roles for each partner organization  To strengthen the commitment from all partners to improve the household and food industry use of adequately iodized salt, and relate this to other fortification efforts  To provide a forum to share and exchange experiences between participating partners  To discuss the applicability of the monitoring framework for the IDD program to other fortification efforts

The workshop was designed to result in a detailed monitoring framework. However, due to airline scheduling changes, the workshop was condensed from 4 to 3 days, and there was not adequate time to go through specific indicators and data collection systems. As a result, a monitoring framework (see below) has been developed following the workshop to be used as a starting point to stimulate further discussion among the stakeholders, and ultimately result in a framework for which there is a consensus among all concerned.

This workshop follows a series of workshops completed in Moldova, Georgia and several other countries in the region. In 2004, a team from Tajikistan participated in a monitoring training in Almaty, organized by CDC, which laid the basis of understanding, which the current workshop built on.

Current Situation

Two reports lay the groundwork for understanding the current situation—the recent micronutrient status survey, and a previous salt situation analysis report. The current micronutrient situation in Tajikistan is best described by the findings of the report on the Nutrition Status of Mothers and Children in Tajikistan.1 The survey assessed anemia and iron deficiency, iodine deficiency, folate deficiency, feeding patterns in infants and young children, and dietary intake among non-pregnant women of reproductive age. The survey was representative at the level of each of the 4 oblasts: Khatlon, RRS, Sughd and GBAO).

4 The following table summarizes the findings from the survey, noting national figures and the worst situation for any given oblast.

Table 1: Summary of iodine and iron deficiency (National Micronutrient Survey 2004)

Indicator Target group Children 6-59 mo. Women (15-49 yrs) Household % low BMI 9% (< 18.5 kg/m2) (20% in GBAO) Anemia 38% 41% (based on (55% in GBAO) (63% in Khatlon) hemoglobin) (% < 11.0 g/dL) (% < 12.0 g/dL) Iron deficiency 39% 29% (based on serum (51% in Khatlon) (36% in Khatlon) transferring receptor) (>8.5 mg/L) (>8.5 mg/L) Folic acid 74% deficiency (sub-sample 300 (< 3.0 μg/L) women) Median urinary 73.1 μg/L 93.6 μg/L iodine (64.5 μg/L in (65.7 μg/L in (adequate: 100-199 Khatlon) Khatlon) μg /L) % of population w/ 40% 35% moderate to severe deficiency)

(< 20% of population with UIE < 50 μg/L) Aware of iodized 85% salt % of HH using 52% iodized salt (per test (21% in Khatlon) kit—presence of iodine) (any color change) % of HH with 28% iodized salt (> 15 (13% in Khatlon) ppm per test kit) ( > 15ppm)

With regard to the iodine deficiency elimination program, the survey data raise a number of important questions. First, the proportion of households using adequately iodized salt (> 15 ppm) was 28% while the proportion inadequately iodized salt (1-14 ppm) was 24%. With adequate production level quality assurance, and in the absence of unexpected

5 losses from production to the marketplace, there should not be such a large proportion of households using salt with inadequate iodine. This raises questions about whether production level quality assurance measures are adequate. Second, the survey used only qualitative salt test kits, and thus the variation between different observers testing the salt during the survey is likely to be high. This raises an alternative explanation for the survey findings, that is, that this observer variation limited the accuracy of the survey data. Improvements in the monitoring framework could help address these questions.

With regard to salt production, a salt situation analysis was completed in Tajikistan in 2002 2, and provides information on production capacity. With an estimated population of 7 million and an average household consumption of 10 g/person/day, the estimated iodized salt need would be 25,500 metric tons per year. The salt situation analysis estimated an annual need of 35,000 tons (approximately 13.7 g/person/day).

There are three large para-statal salt producers, including Asht in the North, Voce in the south, and Yavan closer to Dushanbe. Each has close to a billion tons estimated reserves —adequate to meet the salt needs for Tajikistan for the foreseeable future. UNICEF has assisted each with iodization and quality assurance capacity, and each uses potassium iodate. The 2002 report summarized production figures as follows:

Table 2. Current annual production (tons) based on 2001 2 Producing Capacity Actual Edible Iodized Salt Technical Facility Production Salt Grade ASHT 31,000 28,700 15,400 13700 13,300 VOCE 42,000 23,700 18,500 10800 5200 YAVAN 60,000 6,000 6,000 6,000 NONE TOTAL 133,000 58,400 39,900 30,500 18,500

Each facility demonstrated an increase in iodized salt production from 2000 to 2001 according to the report. However, production for the Yavan facility was disrupted because of financial difficulties and power outages for much of 2004, with production just beginning in mid-2005.

This report also raises several questions. There appear to be discrepancies between the estimated iodized salt need, the total salt production tonnage figures, and the iodized and edible salt tonnage figures. With mandatory salt iodization, why is there still such a relatively large proportion out of the total amount of edible salt produced, non-iodized salt (9,400 tons out out 39,900 tons total)?

These production figures do not even take into account the production figures from small producers. There are several areas of the country in which there is rock salt or brine available to surrounding villages, and some local production is done in these areas, including small-scale commercial production. The salt report mentions a large salt deposit at Sherbele, near Murghab, in Gorno-Badakshan Oblast, and there are apparently some other deposits as well. The overall contribution of these small scale ‘producers’ is not clear, but has been estimated to contribute as much as 20% of total salt production.

6 In addition, the current production figures for iodized salt do not correspond to the national survey data on household use of adequately iodized salt (28%). If total production tonnage represents 87% of estimated need (30,500/35,000), why is there such a low household coverage figure? With only one of these producers exporting iodized salt, where does the rest of the iodized salt go? Several questions come to mind: Are the survey data correct? Are the salt production data correct? Is the salt quality assurance system functioning in the large factories?

The appearance of technical salt in the retail market has been suggested as one of the reasons for the discrepancy between iodized salt production and household use. Another explanation could be the counterfeiting of salt (non-iodized salt packaged and sold as iodized salt). The extent of both problems has not been assessed, however.

The emerging picture from these two reports is that iron, folic acid and iodine deficiency remain significant public health problems in Tajikistan. Furthermore, in spite of adequate production capacity, mandatory salt iodization and high awareness of iodized salt, most households do not use adequately iodized salt, although this figure has risen from the MICS survey result from 2002 of 20% use of iodized salt. There is significant variation between oblasts in levels of deficiency, and in household use of iodized salt, perhaps related to both distance from production facilities and the contribution of local production. The issues raised with these reports suggest that improvement in monitoring can help answer a number of critical questions, and help guide the program toward higher iodized salt use. The workshop was designed with these considerations in mind.

Workshop Preparation and Proceedings

The day after arrival, a field trip was made to the Yavan salt production facility, and a brief meeting held with the technical staff there, including the laboratory staff. A visit was also made to a town holding an orientation for community groups on the importance of iodized salt—a communication effort supported by UNICEF, and implemented by local NGOs.

The agenda for the workshop was developed prior to the workshop, based on previous workshop agendas. A participant list was developed by UNICEF/Tajikistan, and included broad representation from different stakeholders (see appendix). Some materials were distributed ahead of time, and presentations for the workshop were translated into Russian. Simultaneous translation service was provided throughout the workshop. All presentations in Russian and English were provided to participants as a reference CD-ROM.

Prior to the workshop, several meetings were held between the facilitators and the UNICEF staff. These meetings resulted in last minute modifications to the agenda—in part necessitated by the change in Tajik Air schedule, which required facilitators to leave

7 earlier than expected (see appendix for full agenda). In addition, some modifications to several presentations were made.

The workshop involved approximately 30 participants. Following an orientation and session on participant views of current issues, there were presentations for each program element, followed by full group discussion, small group work, or both. The workshop concluded with a session designed to develop a monitoring and evaluation framework, which did not achieve the level of detail to define indicators and roles and responsibilities. A monitoring framework with this level of detail is proposed as a starting point for future discussions, and is included in the appendix.

Discussion and Recommendations

With legislation in place, regulations defined, and adequate production capacity in country, Tajikistan is well set up for a successful salt iodization program. However, in spite of improvements recently, iodine deficiency remains, and both household use and the quality of iodized salt reaching households is less than optimal.

The discussions during the workshop raised a number of important issues affecting the IDD program. These issues are complex, and highlight the importance of an improved monitoring system that can provide adequate data with which to answer the questions raised. The following discussion includes program implementation, production and monitoring progress, and includes recommendations at the end of each section.

A. Program Implementation

Policy, advocacy and political will

There appears to be excellent political support for the IDD program, and this is having a positive effect on the broader issue of fortification for Tajikistan. The recent micronutrient survey again highlighted the urgency of the problem. However, this support will need to be maintained in light of the progress that needs to be made.

In theory a National IDD Committee exists that is charged with the programme management and oversight function. However, in reality, the Ministry of Health is the lead agency in managing the IDD elimination efforts, but is not very actively engaged. A National Action Plan for Nutrition was developed with participation of international experts in June 2005, which laid out the activities for salt iodization as well.

Legislation and Regulation

Legislation and regulations are firmly in place, and there does not appear to be any group resistant to the recent law mandating iodization. An inspection system exists, with clear guidelines on salt testing from production to retail shops. The reality shows, however,

8 that the enforcement system is weak, susceptible to corruption and therefore needs more high-level commitment in order to become more effective.

In spite of the law mandating iodization, there has been some ambivalence toward shutting down small-scale local production, which seems to be concentrated mainly in Khatlon Oblast—partly because of the transitory nature of these enterprises, and partly because the enterprises have been given local ‘rights’ to produce salt. It is not clear whether the regulatory authority alone can curtail the availability of non-iodized salt reaching the market in these areas.

Laboratory Capacity

The laboratory at the Yavan facility uses titration for quality assurance, as does the Asht facility. The current status of the Voce facility is not clear. Government laboratory capacity for testing salt exists centrally and at the oblast level. However, it is not evident that the quality assurance system at production level in functioning satisfactorily, and this requires close follow up with the salt producers and the inspection agencies.

Urinary iodine assessment for the micronutrient survey was done in Tajikistan, though it is not clear to what degree the lab participates in an international quality assurance program to ensure lack of contamination with environmental iodine. UNICEF Regional Office has commissioned a regional assessment of all urinary iodine and salt laboratory facilities, their quality of work and the system for external quality control. The effort will also aim at setting up a system with regional resource laboratories (in Kazakhstan, Russia, Bulgaria and Belgium) to perform routine Round Robin and external quality control built in as part of any urinary iodine and salt analysis.

Information, Education and Communication

There is a well-developed communication plan for the IDD program, and this is being implemented sequentially in different geographic areas. The plan includes involvement of local NGOs, and orientation to community leaders, health workers, and teachers on the importance of iodized salt to eliminate IDD. There is some evidence of the success of this plan in the improvement in household iodized salt use between MICS and the recent micronutrient survey.

There are several unanswered questions concerning consumer preference:  How strong is consumer demand for iodized salt, and what are the key constraints to purchasing iodized salt given the high level of awareness?  What are the decisive factors for consumers to prefer salt from small producers over iodized salt: price, quality or other factors?

 What are consumer perceptions on home use of non-iodized salt for food processing, and can these be changed through building awareness?

9  Can promotional activities affect local purchasing habits in areas with high local production of non-iodized salt?

As with other countries, there are conflicting rumors about consumer preference. Pickling and home food processing is traditional, and it is likely that some of the concerns documented in other countries in the region apply in Tajikistan as well. However, there have not been any studies exploring this issue in depth and its extent. To complicate the picture, there have been production lapses and some indication of lack of availability in some oblasts. It is therefore not clear what the overall contribution to low household use is from lack of availability, presence of local salt, or consumer preference, or some combination of these.

Advocacy recommendations:  The IDD committee needs reactivation and to be charged with engaging partners, collecting, compiling and reporting monitoring information, and providing a inter- agency coordinating body.  The MoH as the leading national authority should act as chair for the IDD committee.  Salt producers need to be more actively involved in the coordination activities, including having strong representation on the IDD committee.  A continued long-term advocacy program is recommended to sustain the current level of political support.

Regulatory recommendations:  High level political support should be sought for improving enforcement of mandatory salt iodization. The achievement of the goal of sustainable elimination of iodine deficiency and protection of young minds from decreased learning capacity due to iodine deficiency requires more dedicated enforcement and collaboration of involved gatekeepers.  Further discussions should be held with local leaders in areas with low iodized salt coverage on the importance of finding a mechanism for iodizing local salt (or ending its production.)

Laboratory recommendations:  Quality assurance measures should be reviewed at each production facility, and gaps in sample collection, analysis, procurement of reagents, and reporting should be addressed.  One laboratory should be assigned to perform future UI measurements, and the lab should participate in an intra-laboratory quality assurance (sample exchange) program, if not already in place.  Information collected should be compiled and reported on a more regular basis and be made available to all IDD committee members.

IEC recommendations:  A series of qualitative studies are recommended to provide better information on consumer preferences and purchasing behavior.

10  These studies should be linked to market availability data to help understand the relationship between availability and consumer usage of iodized salt.

B. Iodized Salt Production and Distribution

A number of factors have affected iodized salt production recently. There have been production delays because of power shortages and financial difficulties. There has been a transition from full subsidy of potassium iodate, to establishment (with UNICEF support) of revolving system that places procurement responsibility on the producers. However, even with these difficulties, the discrepancy between iodized salt production capacity and household coverage raises a number of fundamental questions. The monitoring system needs to provide information to address the following gaps in understanding of the salt situation:

 Are the three main producers able to produce a consistent supply of iodized salt to meet the needs of the country?

There was a major disruption in salt production at the Yavan facility, which may have resulted in lack of availability of iodized salt in the market in many areas served by this facility. It is not clear whether other facilities also had disruptions, or whether they were able to produce adequate quantities to ensure availability in all oblasts. As para-statal organizations, production facilities can benefit from some government oversight to insure continuous supply of salt to the population.

 Is the iodized salt leaving production facilities consistently adequately iodized?

Laboratory facilities allegedly exist and are functional at all of the three main production facilities. However, the salt report notes that for the Voce facility, at the time of the report, there was no laboratory, and thus no quality assurance procedure. At the Yavan facility, a good laboratory exists, but at the time of the visit, there had been no recent salt testing due to production stoppage. It is not clear how often samples are routinely checked at each facility, nor is it clear how these data are managed.

 How much of a contribution does locally produced salt make to overall salt consumption?

There are 76 small salt enterprises ‘registered’, although many more may collect salt and sell a portion to local villagers. There is currently no data on the quantity produced by these enterprises. By one estimate, a maximum of 100 tons per year is produce by each enterprise, which would result in about 7600 tons produced for that locality. This may be enough to affect iodized salt use, since this local salt is cheap, and may displace use of the more expensive iodized salt even if that were available. Although this figure is small, it does reflect over 20% of estimated national annual need. There has been some work to have these enterprises pool their salt and sell to either a larger producer, or to a

11 cooperative salt iodization facility. Currently there are limited data on these enterprises, and how their production is being affected by the recent legislation.

 What proportion of salt available in retail shops, and used in households is counterfeit—labeled as iodized, but containing no iodine?

There is anecdotal evidence that some counterfeiting exists, but little data to clarify the actual situation.

 To what degree does import of salt (iodized and non-iodized) contribute to household use patterns? How does export of iodized salt produced in Tajikistan affect availability of iodized salt in Tajikistan?

Currently, there is no evidence of significant import of iodized salt, although this certainly could be possible given the production capacity in surrounding countries. However, there are no data from customs or other government agencies on imported salt.

Reportedly, the only facility currently exporting iodized salt is the Yavan facility—the others do not export salt. The production data from the Yavan facility do not present a clear picture of how much salt is usually exported, and how this relates to supply of iodized salt to local markets. The production data suggests an overcapacity, which implies a substantial amount being exported.

Production/distribution recommendations:  A protocol should be developed that defines government measures to insure continuous production and supply of iodized salt from parastatal production facilities  Current quality assurance practices for each producer should be reviewed and standardized if needed, ensuring adequate sample testing by titration.  External quality control needs to be strengthened to verify the functioning of the quality assurance at factory level.  External quality assurance information should be compiled and reported on a more regular basis and be made available to all IDD committee members.  Small qualitative studies are recommended to provide information on the contribution of small enterprise producers to overall household salt consumption. In addition, the potential for iodization of salt produced by these small factories should be explored.  Counterfeiting should be addressed as part of the monitoring system, by identifying the source of the problem (location of practicing counterfeiters) and its extent together with punitive action by the responsible agencies.  Small studies should be done to determine the contribution of technical salt to household consumption  More accurate information should be continuously collected from salt producers on export of iodized salt, including the amount exported, name of producer and destination of exported salt, broken down by iodized/non-iodized salt. Agreements

12 and incentives for exporting iodized salt in the face of needing to meet local needs should be explored.  Customs records should be reviewed to determine the quantity of salt imported, and recommendations made to revise reporting so this tonnage figure becomes more readily available.  A salt producers association could play a central role in addressing some of the pertinent programme concerns that currently exist. UNICEF should stimulate the formation of such association and discuss the inclusion of tasks related to collecting, compiling and reporting production data, strengthening quality assurance capacity, and discussing salt cooperatives and other solutions for small salt producers in Khatlon oblast. UNICEF should consider actively supporting the salt producers association.

C. Measuring Progress

Coverage Estimation: (proportion of households using adequaltely iodized salt)

Both MICS and the Micronutrient Survey provide household coverage estimates, and these are representative at the oblast level in the latter. Thus there are adequate data on recent coverage by oblast. However, it is not clear to what degree the differences in coverage has stimulated investigation into the causes of low coverage in certain oblasts. Furthermore, the overall national figure is quite low, requiring attention to determine the main causes, since there are questions about both availability and consumer preference.

These figures will need to be re-assessed, since they are critical to direct the communication plan and to address the problem areas. With the discrepancy (described earlier) between adequately iodized and inadequately iodized salt at the household level, it is critical to use quantitative measures to better understand these data in future surveys.

Ideally, the monitoring system should provide accurate coverage estimates on an annual basis, either from survey data or from other sources. These data should be correlated with data on the tonnage of iodized salt produced and the estimated daily per capita consumption. Monitoring iodized salt production figures is critical given the long lapses in salt production already experienced.

Impact assessment

The recent survey provides excellent urinary iodine assessment in women and children, stratified by oblast. The low values found should continue to be used for advocacy, and to stimulate closer monitoring of both iodized salt production and use.

There are currently two systems in place to monitor goiter. First, there is health facility reporting of the total number of goiter cases recorded, differentiating between new cases, and existing cases. There is also an extensive system in place to do clinical assessment/screening of goiter among school children.

13 These established systems continue to provide for examination and reporting on goiters, both total numbers and estimated prevalence. However, it is not clear to what degree these data are used to strengthen the salt iodization program, or to address the causes of continued high prevalence. While the trend in total goiters recorded has declined nicely, the prevalence of goiter among school children has stabilized. This may reflect the difficulty with goiter grading for grade I goiters, or the documented residual prevalence of small goiters among populations recently deficient. While this system is well established, it is not clear whether it is valuable in monitoring progress with the IDD program in general.

Urinary iodine assessment is usually done periodically, perhaps every 5 years. Household coverage is used as a measure of program success, and with good quality assurance and high coverage, urinary iodine is likely to revert to normal. Goiter grading is suspect in endemic populations even with correction of iodine deficiency. Thus it may be valuable to consider revising the goiter assessment activity to focus on improving iodized salt coverage.

Coverage/impact recommendations:  As part of the upcoming MICS survey, conduct quantitative analysis (titration) of iodine in salt. Salt samples should be collected, sealed, and transported to central location for cross-checking using titration. In addition, repetition of rapid test kit can be carried out and compared with the on-the-spot test results to assess the inter-measurer variation.  All future national surveys (or surveys done at the oblast level) should include some questions on household salt use and assessment of salt samples using titration.  A brief annual report should be generated on estimated household coverage with adequately iodized salt, summarizing the current situation.  The routine screening for goiter involves a large effort (number of staff and time), which from management perspective could be used otherwise to directly benefit the salt iodization effort. Therefore, the MoH should consider whether mass screening of school children is a wise use of available resources.

Development of a Monitoring Framework

Given the gaps in information related to the IDD program, strengthening the monitoring framework used to provide regular accurate information is important for program guidance. The framework should define the information to be collected, the institution responsible, the criteria and guidelines for collection, and the reporting and use of the information collected. Such a framework, once implemented, should provide adequate information to answer the questions still facing the program.

14 The workshop was designed to provide a forum for building consensus for such a framework. However, because of time limitations, the details noted below were not developed during the workshop, but instead have been developed based on the discussions at the workshop. The framework is presented here for further discussion among stakeholders involved, and is presented it two ways. First, it is organized according to the level of monitoring—following the discussion during the workshop. Thus, the monitoring activities needed during production, at the wholesale and retail level, at the household level, and to measure impact are all included. Second, the same information is organized in such a way that it helps answer several key questions facing the program.

15 Draft Monitoring Framework

Monitoring Reporting Information to be collected By Whom How Use of information level frequency Production # tons all salt produced Salt Continuous record Quarterly, or upon  To compare to estimated level: # tons iodized salt produced producers request from the quarterly need # tons technical salt produced Ministry of Health,  To review ratio Monitoring # tons exported IDD committee, iodized/technical salt done by And/or Salt  To estimate annual coverage producers  Names and location of food producer  To assess production industry customers and association (SPA) disruptions technical salt customers  To trace food grade salt and track technical salt in retail market  To direct corrective actions Used also by IDD Task Force; IDD program manager # tons potassium iodate procured Salt Continuous record Once / 4 months or  To verify estimated tonnage of # tons potassium iodate used producers upon request from iodized salt produced the ministries/SPA as needed % of samples tested meeting Salt 8 samples from 5 Quarterly, or upon Production level quality assurance: government standard producers places in request from the provides record that salt produced production line Ministry or SPA meets standards tested during one shift or

Random selection of minimum of 4 samples per batch; testing by titration

16 Monitoring Reporting Information to be collected By Whom How Use of information level frequency Production Review of tonnage records as Standards Random Annual  To compare to estimated level: noted above Agency, unannounced quarterly need Oblast level production facility  To review ratio Monitoring Review of quality assurance visits; minimum 2x iodized/technical salt done by records SES per year per facility  To estimate annual coverage government (in case a problem  To assess production exists, more disruptions frequently)  To trace food grade salt and track technical salt in retail market  To direct corrective actions % of government collected Standards Random Annual To confirm quality assurance at production level samples meeting Agency, unannounced production level standard Oblast level production facility visits; minimum 2x To enforce mandatory salt SES per year per facility iodization of salt for human (or more frequent consumption if problem exists)

Minimum of 20 samples from production line per visit; testing by test kit and titration Estimated # small enterprise salt Standards Special study Once for special To assess relative contribution of producers Agency: study; annual small enterprise salt producers contract reporting Estimated # tons produced by thereafter such enterprises

Total tons iodized/non-iodized Customs Routine recording Ongoing To estimate the total amount of salt imported of imported iodized and non-iodized salt products entering the country 17 Monitoring By Whom How Reporting Use of information Monitoringlevel Information to be collected Reportingfrequency By Whom How Use of information level Information to be collected frequency Retail level: % of retail shops with iodized salt SES, Random selection Annual To confirm availability of iodized Wholesale availableStorage and warehousing consumerSES or ofRandom shops Annual salt,To by confirm oblast (withthat wholesalers focus on level: conditions (FIFO, expiration community unannounced oblastsconform with tolow government use of iodized %dates) of retail shops with non-iodized groups in Ideallywholesale 1-2 facilityshops salt)regulations tablePresence salt available of non-iodized salt low use pervisits; village minimum per year 2x  To identify sources of Presence of technical salt areas per year per facility To counterfeitedconfirm adherence salt and to lawtechnical %Presence of retail ofshops counterfeited repackaging salt salt (possible?) prohibitingsalt for retailsale ofdestination non-iodized into% ofsmaller retail shopsunlabeled repackaging packages salt table salt into smaller unlabeled packages %Estimated of retail shopsof storage stating time; SES As above Annual ToTo confirmunderstand reasonable large package warehouse salt disruptionaverage time of iodized to expiration; salt supply % ofin proceduresmanagement practices lastsamples 6 months expired To estimate transit time To document disruptions in % of wholesale samples meeting SES As above Annual iodizedTo assess salt supply losses from government standard production to wholesale level Recording of packaging/labeling:  To estimate average retention %(iodized, of retail non-iodized, samples meeting bulk SES Minimum 200 shops Annual To ofconfirm iodine adequacy at wholesale of iodine level governmenttechnical, bulk standard iodized) sampled per oblast contentTo identify at retail sources level of per year; testing by counterfeited salt % of packaged retail samples with test kit and titration To identify potential counterfeit no iodine (Note:brands, as or program brands not matures, adhering and to qualitystandards assurance improves at production level, wholesale monitoring can be de-emphasized) % of retail shops carrying small SES As above Annual To identify small scale salt enterprise (low quality) salt with enterprise non-iodized salt no iodine entering market

18 Price differential between retail SES Special annual data Annual To determine whether price iodized salt, and production sales collection differential is likely to contribute to price to wholesale/retail markets low household coverage

Monitoring Reporting Information to be collected By Whom How Use of information level frequency Household % of households with iodized salt Preventive Household survey Periodic; once To provide coverage estimate level: available at time of survey: medicine (specific to IDD every 3-5 years  % HH samples w/ no iodine service program or tagged To assess use and availability of (0 ppm) to other national or non-iodized salt  % HH samples w/ some Medical oblast survey) iodine (1-14 ppm) University To identify counterfeit salt (non- Salt tested by test iodized salt packaged as iodized) % of households with adequately kit and titration iodized salt (>14 ppm) available at time of survey (by titration) % of respondents stating use of Preventive Survey module on Periodic; once To define the proportion stating non-iodized salt in home based medicine household salt use every 3-5 years preference for non- food processing service practices iodized/technical salt for food processing or home use % of respondents stating use of Medical technical salt for home use University

19 % of respondents stating Preventive Survey module on Periodic; once To assess consumer awareness of awareness of iodized salt medicine household salt use every 3-5 years the importance of use of iodized service practices salt to prevent IDD % of respondents stating understanding of the risk of Medical iodine deficiency in terms of University impaired intellectual development

20 Monitoring Reporting Information to be collected By Whom How Use of information level frequency Monitoring Median urinary iodine: Preventive Periodic special Periodic To confirm expected reversion of impact:  among women of 15-49 years medicine study median UI to normal in light of high old (ideally including a sub- service HH coverage sample of pregnant women)  among school children Medical University % of target group with UI < 50 μg/L

Note: sub-national data are required) # goiter cases presenting to Health Routine reporting Annual To follow trend in new goiter cases health facilities facilities through HMIS as reflection of elimination of IDD  Total # cases  # new cases

(Note: other than routinely reported facility cases, continuation of goiter examination in school-children should be de-emphasized or phased out)

21 Appendix I: Monitoring Framework Organized Around Key Questions

Program Question Current concerns

1. Is all edible salt currently produced in 1. 46% currently not iodized (2003 survey) or imported to Tajikistan iodized? 2. Counterfeiting 3. Amount exported 4. Small producers in Khatlon oblast 5. Substitution of technical salt 6. Price differential 7. Consumer preference re food processing?

Information needed Level of collection Source/responsibility

# tons all salt produced Production Producer # tons iodized salt produced # tons technical salt produced # tons potassium iodate Production Producer procured # tons potassium iodate used % of samples tested Production Producer meeting government standard % of government collected Production Standards agency production level samples SES meeting standard Estimated # small Production/market Special study enterprise salt producers Standards agency?

Estimated # tons produced by such enterprises Total tons iodized/non- Importation Customs records iodized salt imported

Recommendations

 Review accuracy of production figures by audit or special review  Strengthen fortification alliance so they can assist Tajik Standards with use of production data  Lobby for more government funds allocated for monitoring iodized salt

22  Design and complete special study of small enterprise salt production and sale, and its contribution to low household coverage  Review licensing and certification of quality procedures

Program Question Current concerns

2. Is all iodized salt adequately iodized? 1. 24% inadequately iodized (2003 survey) 2. Quality assurance at production level 3. Quality of salt (particularly among small enterprise) 4. Use of test kit vs. titration 5. Consistency of KIO3 availability 6. Loss of iodine in salt after production

% of samples tested at Production Producer production level meeting government standard % of government collected Production Standards agency production level samples SES meeting standard % of wholesale samples Wholesale SES meeting government standard % of retail samples meeting Market SES, consumer or government standard community group?

% of packaged retail samples with no iodine

Recommendations

 Review capacity of SES for sample collection and geographic distribution  Include titration for all or a sub-sample of all salt tested to insure accuracy  Review lab capacity at Voce facility; summarize all 3 production facility internal quality assurance measures for past year

23 Program Question Current concerns

3. Do all households use iodized salt? 1. 28% adequately iodized (2003 survey) 2. Production data imply higher use than 28% 3. Consumer preferences not known with regard to pickling, food processing 4. Price differential iodized vs. non-iodized 5. Local availability of low quality salt

# tons iodized salt Production/Customs Production/import records produced/imported per year MOH divided by the estimated total population need (35,000 tons) % of households with Household survey adequately iodized salt MOH available at time of survey, based on titration % of respondents stating Household survey use of technical salt for MOH home use % of shops having iodized salt available % of shops selling technical or counterfeited salt

Recommendations

 Review reporting procedures for production level tonnage reporting to avoid duplicate reporting; review accuracy of tonnage figures reported  Review past studies on consumer preferences; complete qualitative study on consumer preferences and use of non-iodized salt or technical salt; include review of role of price in consumer choice

24 Program Question Current concerns

4. What is the iodine status of the 1. Women 94 μg/L; School children 73 population? μg/L median urinary iodine (2003 survey) 2. Geographic variation and sub-national assessment 3. Use of goiter as an indicator 4. Contribution of iodized salt use in table salt vs. food industry

Median urinary iodine: Household Survey  among women of 15-49 MOH or University study years old (ideally including a sub-sample of pregnant women)  among school children

% of target group with UI < 50 μg/L Geographic variation in UI Household Special study or survey values MOH or University study

Recommendations

 Consider revising school-based goiter grading to method to ascertain household use of iodized salt  Consider small-scale survey in suspected high endemic areas to clarify median UI among women and children—compare against known HH coverage  Review current use of iodized salt in key industries including bread, biscuits, noodles and other processed foods

25 Appendix II: Workshop Agenda

National Workshop IDD Program Monitoring ADB Project Meeting Room Dushanbe, Tajikistan August 1-3, 2005

Workshop Method:

The workshop will be highly participatory. Brief introductions on technical and programmatic topics will be followed by working group discussions. Participants will identify strengths and weaknesses of different aspects of the IDD elimination program, and exchange experiences with colleagues from different sectors. This approach will allow participants to: - Understand all aspects of IDD program monitoring and reflect on the situation in their country - Review each monitoring area to identify constraints and recommendations for its operation - Report back to the group - Generate discussion and comments from others with a wide range of expertise

General Format:

The workshop will be organized around four conceptual steps in the development of a monitoring plan:

Part 1: General overview and background of the situation in Tajikistan

Part 2: Detailed review of each level of monitoring to provide a reality check on activities required to monitor at that level, and the actions to be taken in response to monitoring information. This will result in a monitoring framework describing what information is to be collected, who will be responsible for collection, how often information will be collected, and how that information will be used.

Part 3: Outline of the overall management of the monitoring system, including reporting formats, determination of users of the information and mechanisms for feedback.

Part 4: Development of an action plan on how to implement the monitoring framework and follow-up, and further discussion on applicability to other fortification efforts.

26 Workshop agenda

DAY 1: Monday, 1 August 2005  Introduction and Background  Regulatory Environment Time # of Topic and format Speaker, instructor Material minu We need to identify tes chairperson for ½ day and discuss rapporteur 8:30 30 Registration Nigina, SES 9.00 30 Opening remarks and ceremony Mr Afgonov, Dep MoH Yukie Mokuo, UNICEF Rep 9.30 15 Presentation: Why are we here? Robin Houston Powerpoint Background and workshop objectives

9.45 30 Introductions by participants (full group) 10.15 30 Coffee break 10.45 15 Expectation exercise Mutrib Bakhruddinov In written form, 3 points, done individually by all participants 11.00 30 Presentation: IDD Elimination: Arnold Timmer powerpoint Regional Overview 11.30 30 Presentation: IDD elimination Ms. Kasimova. Head of the powerpoint situation in Tajikistan Republican endocrinology dispenser 12:30 60 Lunch 13.30 30 Presentation: Key IDD/USI Arnold Timmer powerpoint program elements: A review Manual: Monitoring including a monitoring USI programmes framework 14:00 30 VIPP session: Problem analysis Robin Houston Group work of key issues instruction 1) Introduction Colored carton cards 2) Individual exercise 14:30 40 Coffee break 15:10 50 Analysis and discussion of key Robin Houston tape, cards problems John Egbuta Arnold Timmer 16:00 30 Presentation: The regulatory Robin Houston powerpoint environment: Issues and questions 16:30 30 Presentation: Current regulatory Abdusalom Vahidov, ADB environment 17.00 30 Full group discussion: The Robin Houston legislative and regulatory issues Arnold Timmer John Egbuta 17:30 End of day 1

27 DAY 2: Tuesday, 2 August 2005  Monitoring at the Production and Import Level  Monitoring At Wholesale and Retail level  Monitoring at the Household Level Time # of Topic and format Speaker, instructor Material minu tes 8.30 45 Presentation: Monitoring at the John Egbuta powerpoint production and import levels: Issues and questions 9.15 30 Presentation: Salt production quality Mrs Lola powerpoint assurance at production level: Usufakhmedova, producer perspective Koni Namak Company

28 9.45 60 Small group work: Strengthening 3 group work monitoring at production, importation level (includes coffee break) 10.45 45 Group presentations: Monitoring production, importation, including related regulatory environment issues 11:30 45 Discussion: Monitoring at the production and importation level 12:15 60 Lunch 13:15 30 Presentation: Monitoring at wholesale Arnold Timmer powerpoint and retail level 13:45 30 Presentation: Country experience Mr Sultonov, Powerpoint Current situation for inspection, Standard Bureau control, monitoring , and quality assurance 14.15 60 Small group work: Strengthening monitoring at wholesale and retail level (includes coffee break) 15.15 30 Feed back and discussion: Monitoring at the wholesale and retail level 15.45 30 Presentation: Monitoring at the Robin Houston Powerpoint household level, including determination of coverage 16:15 30 Presentation: Models for household Mr Azonov, Institute Powerpoint assessment/monitoring of Nutrition 16:45 30 Presentation: Iodine stability in salt: John Egbuta Powerpoint implications for packaging, distribution and storage, and consumer habits 17.15 45 Full group discussion: Monitoring at Robin Houston Powerpoint household level Philip Makhumula Arnold Timmer John Egbuta 18.00 End of day 2 Day 3: Wednesday, 3 August 2005  Monitoring impact  Management and Use of Information Collected  Development of an Action Plan Time # of Topic and format Speaker, Material mins instructor 8:30 30 Presentation: Periodic impact Robin Houston Powerpoint assessment: a brief overview of indicators and methods 9:00 30 Presentation: Laboratory issues Mrs Rano Powerpoint Nazirova, SES 9.30 30 Full group discussion: Periodic impact Robin Houston assessment Philip Makhumula Arnold Timmer John Egbuta 10:00 30 Coffee break

29 10:30 30 Presentation: Definitions: Inspection, John Egbuta Powerpoint control, and quality assurance 11:00 30 Presentation: Use and interpretation of Arnold Timmer Powerpoint data:  Data management  Interpretation of results  Reporting of data: what is essential  Use of data: for programme management and advocacy 11.30 30 Presentation: Salt testing: strengths and Philip Makhumula Powerpoint weaknesses of titration and salt test kits 12.00 15 Group work instruction: Development Robin Houston Group work of an action plan instruction 12:15 60 Lunch 13:15 150 Small group work: Putting it in Work in small practice: Action plan. groups  Who does what? Definition of institutional roles  Interpretation and use of data  Enforcement  Data flow and management  Response to low salt iodine content  Response to low coverage  Identify constraints and how to overcome them (includes coffee break) 15:45 90 Plenary: Presentation Tajikistan Tajikistan group Monitoring framework and Action Plan representative Discussion and feed back 17.15 15 Evaluation Arnold Timmer 17.30 Closing Representatives from MoH, MoI and UNICEF

Appendix III: List of participants

Name Position 1. Sultonov I. State standard Agency 2. Khakimov R. Standard Agency, Sogd oblast 3. Rasulov A. Standard Agency, Khatlon oblast 4. Sharipov Sh. SES, Kulyab region 5. Kholov Z. Endocrinology Center, Khatlon oblast 6. Boboev Kh. Ministry of industry 7. Talbakov Sh. Republican SES 8. Nazirova R. Republican SES 9. Kurbonov M. SES, Sogd oblast 10. Kasimova Salomat Republican Endocrinology Center

30 11. Polvonova M. Endocrinology Center, Sogd oblast 12. Khairov Khotambek Nutrition Center, Director 13. Norkulov Nutrition Center 14. Shomurzoev A. Asht salt Factory 15. Vohidov Abdusalom ADB project coordinator 16. Bozorov S. SES Khatlon oblast 17. Jonmurodov Abdusamad ES, Khamadoni district

Organizers UNICEF Tajikistan (1) Mutrib Bakhruddinov, Project Officer UNICEF Tajikistan

Facilitators (2) Robin Houston, MOST project USAID (3) Phillip Makhumula, MOST project USAID (4) Arnold Timmer, Project Officer Nutrition, UNICEF – Regional Office CEE CIS BS, Geneva (5) John Egbuta, UNICEF Kazakhstan

Interpreters

31 Appendix IV: List of materials for distribution (provided as CD-ROM)

RUSSIAN Dismantling myths Gerasimov Salt ISPAT Guide communication Monitoring framework Excerpt ch. 8 Iodine stability Success factors management Worksheet on monitoring IDD overview Russia

Manuals Methods of study and Monitoring of IDDs Monitoring universal salt iodization programs

Presentations Regulatory Monitoring intro Production Wholesale/retail Household Impact Use and interpretation of data

ENGLISH Dismantling myths Monitoring framework Excerpt ch. 8 Iodine stability Success factors management Worksheet on monitoring

Presentations Regulatory Monitoring intro Production Wholesale/retail Household Impact Use and interpretation of data

32 References

1 Nutrition Status of Mothers and Children in Tajikistan: Micronutrient Status Survey, 2003. MOH Tajikistan; Kazakh Academy of Nutrition Kazakhstan; National Institute for Research on Food and Nutrition Italy; Asian Development Bank; WHO; UNICEF. April 2004.

2 Varghese, Pan. Salt Fortification Consultancy Report for Tajikistan. 2002