Outcome : Political support from the PM Redefining IDD : National developmental problem

1. The Turning Point of The Programme:1983 Meeting With The Prime Minister of India: Mrs. Indira Gandhi • Outcome : Political support from the PM • Redefining IDD : National developmental problem • Strategy : From District specific to Universal Salt Iodisation (USI) • Solution : Liberalization of production - Encouragement to private sector • Prime Minister’s 20-point Programme: “Goitre Elimination”

2. Progress since 1983 - 1 1984 : Policy of Universal Salt Iodisation : Private sector encouraged to produce iodised salt 1992 : National Goitre Control Programme (NGCP) renamed as National IDD Control Programme (NIDDCP) 1995 : Independent survey evaluation of USI in Madhya Pradesh ; New Delhi; Sikkim

3. Progress since 1983 - 2 1997 : Sale & storage of common salt banned 1998-99 : NFHS - 2 Survey on Household consumption of iodised salt 13th Sept. : Ban on sale of common salt 2000 lifted by the Central Government

4. Graph of progress of USI at a glance 1983-2000

5. India: Use of Iodised Salt National Family Health Survey – 2 (NFHS –2) : 1998-1999 • 71% consuming salt with some iodine • 49% use adequately iodised salt • (recommended level of 15 ppm or more) • 22% use inadequately iodized salt • 29% use non-iodized salt

6. The World In Which Policies Should Be Made 1) Health Problem/Issue 2) Information + Values 3) Institutional structure for decision making 4) POLICIES

7. World In Which Policies Should Be Made Values CORE VALUES (IDEOLOGIES) Gandhians – Salt as a icon of the freedom struggle SJM – Globalization & Liberalization BELIEFS Casual Assumptions – Iodine & Impurity INTERESTS – Iodine & Import Loose Vs Packaged Small Vs Big producers National Vs Multinational

8. Dr. Denish Moorthy, Ph.D. Student, Centre for Community Medicine AIIMS, who has been associated with Prof. Ramalingaswami since 1999 to take us through the events related to role of values in health policy formulation

9. Year 2000 & Beyond May 2000: Central Government decides to lift the ban on the sale of common salt May - Sept 2000: Communication to elected representatives of Central & State Govt. through meetings & letters Proactive IEC in print & electronic media on importance of IDD elimination & Benefits of iodised salt Sept 2000: - Government lifts the ban at the Central Level - States continue to have the ban

10. Withdrawal of The Ban • National Ban on sale of common salt for human consumption withdrawn • - Government of India, 13th Sept. 2000 • Reason Given: • On point of principle, compulsions in the matter of individual choice in undesirable

11. Current Scenario Of The Ban Andhra Pradesh & Maharashtra - Partial ban continues Kerala - No ban (Status Quo); But recent (May 2001) statewide survey shows IDD as public Health problem Gujarat and Orissa – Lifted the ban Orissa – Restored the ban after 6 months

12. Year 2000 & Beyond Probable factors responsible for lifting of the ban: • PFA Legislation – harassment • Politics of liberalization • Price difference and perceptions • Principle of choice

13. Core Values, Beliefs, Interests: The Three Key Players Common & Iodised Salt Manufacturers + Swadeshi Jagran Manch (SJM) + Gandhians

14. Profile of Common Salt Manufacturers • Statewise production • Gujarat : 73% • Tamil Nadu : 13% • Rajasthan : 9% • Sector wise production • Private Sector : 60% • Un-recognised Sector : 28% (Half in Gujarat) • Co-operatives : 9% • Public Sector : 3% • Category wise production • Small - < 10 acres : 62% • Large - > 100 acres : 28% • Medium - 10 - 100 acres : 10%

15. Profile of Iodised Salt Manufacturers • Number of salt iodisation plants : 964 (Year 2000) • State wise production • Gujarat : 61% • Rajasthan : 13% • Tamil Nadu : 9% • Refineries (Production of refined / vacuum iodised salt) • Installed Capacity : 25 lakh tons • Iodised Salt Production : 8 lakh tons (1998) • Proportion of total production : 8 /44 = 18 % • Sector wise production • Private : 98% • Public : 2%

16. Salt Manufacturers & Traders Repackers (Traders) Salt manufacturers Brand Imitation Medium + Large Scale Small Scale Poor Quality salt With Inadequate iodine content Question of quality and Adequate iodine content of salt Refined Free flowing Salt Good Quality salt With Adequate iodine content PFA Act: Harassment Problems with the PFA Act No problems with the PFA Act Petitioning elected representatives: Lifting of the ban

17. Past • Availability of Technology – Large and medium scale producers cutting into small scale producer’s market • Cooperatives formed to assist the small producers • Issues in PFA Act • Issues in implementation of PFA Act • Proposed plan of action • Availability of Technology – Innovative ways of Cooperation • Issues in PFA Act • Efforts to modify Act • Monitoring of quality of iodised salt by the producers themselves • Certification of product: WTO & ISO 9002 Salt Manufacturers

18. Swadeshi Jagran Manch (SJM) • Points related to ideology • Globalization – “Multinational” and large corporation angle to salt in India • Perceptions about common & iodised salt • Price of iodised salt • Liberalization – Import of iodine – a burden on economy!

19. IDD Control Programme: A National Effort - 1 • Contribution Made For Assessment & Tracking Progress: - By national institutions - With national support - By national scientists - Using national laboratory & equipments

20. IDD Control Programme: A National Effort - 2 • Contribution Made For Control: - Self Sufficiency in common salt production - Indigenous manufacture of salt iodisation plants & accessories - Supported by national technical efforts - Conversion of iodine to potassium iodate done in India - Indigenous packaging - Import of Iodine: (Iodine’s share of Total Indian Imports: 0.005%)

21. Perception about common salt & iodised salt Universal Salt Iodisation (USI) = Legislation = PFA = Iodised Salt = Packaged Salt = = Refined Salt = High Priced salt Crystal - in Jute Bags - 75 Kgs. / 100 kgs. Common salt Powdered - in Polypacks - of ½ Kg / 1 kgs. iodised salt

22. Cost Of Iodine For Salt Iodisation • Total Production of Iodised salt in India : 44 Lakh tons • Iodine Required for Salt Iodisation (30 mg I2 /Kg Salt ) : 144 Tons • Price of iodine per ton : Rs. 7.3 Lakhs (@ US$15.5 / Kg) • Total cost of Iodine required for salt Iodisation : Rs. 10.5 Crore

23. Cost Of Iodine Per Person Per year • Total cost of Iodine required for salt Iodisation : Rs. 10.5 Crores • Rs. 10.5 Crores for 100 Crores population • Cost of iodine per person per year : 10.5 paise

24. Acts and Rules for Salt • “Salt” is declared as an item of food under Essential Commodities Act, 1955 • State governments have been authorized to administer the Act for • Fixing the prices of salt • Its movement within their States, if necessary

25. States/UTs Supplying Iodised Salt Fully/Partly Through PDS - I

26. States/UTs Supplying Iodised Salt Fully/Partly Through PDS - II

27. Gandhian Movement • Their Arguments • Do we need universal salt iodisation? • Why a compulsion for iodised salt? • Salt An Icon of the Freedom Struggle • Why not have a Choice?

28. Do we need universal salt iodisation? • IDD is a public health problem ; Therefore it requires public health solution • The serious irreversible effects of IDD (stillbirths , abortion, neonatal mortality and mental handicap) are not obvious • Prevention (Health Promotion & specific protection – public health approach) is better than Cure (early diagnosis and treatment, disability limitation, rehabilitation – Clinical approach)

29. Yes- A Worthwhile Investment in Health Cost per person per year of protection : 50 paise (less than a price of cup of tea!) Cost benefit ratio (only health effects) : 1:3 If benefits related to education (13 I.Q points) & livestock (increased productivity & yield of eggs, milk, wool, etc) included, then: Cost benefit ratio : 1:10 (This work was conducted as part of the INCLEN Training of Dr. Pandav at McMaster University, Canada, 1990-1991)

30. India: Use of Iodised Salt National Family Health Survey – 2 (NFHS –2) : 1998-1999 Socioeconomic Status & Use of Iodised Salt

31. Scientists Point of View • “Improving beneficial components of diet” does not increase iodine intake • Dietary diversification does not increase iodine intake because: “Iodine deficiency is a disease of the soil” • Therefore the need for universal salt iodisation • Most cost-effective, economical & physiologically safe means of eliminating iodine deficiency is regular continuous consumption of adequately iodised salt “Consumption of Iodised Salt: A Healthy Habit”

32. Dr. Chandrakant S Pandav, Member, Clinical Epidemiology Unit, & Addl. Prof., Centre for Community Medicine AIIMS, who spent his school life at Aga Khan Palace, Pune where Mahatma Gandhi was imprisoned during the Quit India Movement To summarize The Case Study

33. “I would be hard-hearted enough to let the sick die if you can tell me how to prevent others from falling sick” - Mahatma Gandhi

34. Lessons Learnt From NIDDCP • Health Issues are Social,Political & Economic Issues • In the Formulation of Policy in a Democratic Environment, we require: a) Identification of the health problem/issue b) Information to knowledge – - Evidence based data - Effective & efficient intervention to eliminate the problem

35. Lessons Learnt From NIDDCP • In the Formulation of Policy in a Democratic Environment, we also require: a) Formal networks b) Informal networks c) Values – Core values, beliefs, interests • Implementation of policy based only one or two factors will: a) Achieve less than optimum results b) Lead to a retrograde step as seen in the Case Study of NIDDCP

36. World In Which Policies Should Be Made 1) Health Problem/Issue 2) Information 3) Values 4) Institutional structure for decision making 5) POLICIES

37. In Summary… • Iterative Loop: Research – Policy - Programme • World In Which Policies Were Being Made • World In Which Policies Should Be Made – A Case Study of NIDDCP • Lessons Learnt From the NIDDCP • In Summary…

38. Thank You for Your Kind Attention!