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Tracking Progress Towards Sustainable Elimination of
Iodine Deficiency Disorders (IDD)in India:
Partnership at State, Regional & National Levels
Dr Denish Moorthy, Dr C S Pandav, Dr R Sankar, Prof M G Karmarkar
All India Institute of Medical Sciences (AIIMS), Indian Coalition for Control of Iodine Deficiency Disorders
(ICCIDD) &
The Micronutrient Initiative (MI)
Chandigarh28th – 29th February 2004
Outline of Presentation
1) Success in Public Health
2) Research to Policy to Program: The Iterative Loop
3) Partnerships in Public Health
4) Tracking Progress Towards Sustainable Elimination of IDD in Kerala & Tamil Nadu
Success in Public Health
1) Well-defined research question
2) Sound scientific research protocol with qualitative and quantitative components
3) State specific information
4) Inter-disciplinary approach
5) Participatory approach
6) Partnership with private sector
7) Linking research with decision making process Mr. P Hota, Secretary to the Government of India, Department of Family Welfare,
Ministry of Health & Family Welfare
Iterative LoopResearch-Policy-Program
POLICY
RESEARCH PROGRAM
Adapted from: Tugwell P, Bennett KJ, Sackett DL, Haynes RB. The measurement iterative loop: a framework for the critical appraisal of need, benefits and costs of health interventions. J Chronic Dis. 1985;38(4):339-51
Iterative LoopResearch-Policy-Program
RESEARCH
POLICY
PROGRAM
Partnerships
Generate Relevant Research Questions
Adapted from: John Hubley. Communicating Health. An action guide to health education and health promotion
List of questions
Prediction from theories
Discussion with field workers & community
Experience
Reading the research
findings of other people
Decisions Needed by the
Program
Partnerships in Public Health
Why Partnerships?
1. “The main determinants of health & disease lie outside
the realm of direct medical competency” – Sir Douglas
Black, Past president of Royal College of Physicians,
London
2. No single sector -- governmental, commercial or civil
society - has the necessary skills or resources to alone
do what is necessary in all areas
3. For e.g. Business has many types of skills and expertise
needed for effective health improvement
4. Partners share objectives and risks regardless of 1. Different contributions from each partner
2. Different benefits to each partner
Partnerships in Public Health - 1
1. Polio Eradication (Rotary International with WHO, Sovereign
Governments)
2. Iodine Deficiency Disorders Elimination (Kiwanis International,
UNICEF, ICCIDD, WHO,PAMM)
3. Children’s Vaccine Initiative (Rockefeller Foundation, UNDP,
UNICEF, World Bank, WHO, private sector)
4. GAIN (Global Alliance for Nutrition – WHO, Private Industry,
Sovereign Governments)
5. Global Fund for AIDS, TB, Malaria (Sovereign Governments,
WHO, CDC, USAID)
6. Supercourse (Internet for Global Preventive Health) –
www.pitt.edu/~super1/ - Awareness about Prevention
Partnerships in Public Health - 2
6. Mectizan Donation for Onchocerciasis (Merck Inc, WHO)
7. Grameen Bank (Microcredit for poverty eradication – community
partnership)
8. Public-Private Partnerships (PPP) in Healthcare to Deliver the Essential
Services Package (ESP) as part of the Health and Population Sector
Programme (HPSP), Government of Bangladesh, 1999-2004
(Government of Bangladesh, DFID, NICARE/British Council, NGOs)
9. TB & You (Forging partnerships with NGOs (Bangladesh Rural
Advancement Committee),Media, Private Health Sector (Andhra
Pradesh – State TB Unit and Private Hospital), Policy Makers, Donor
Agencies)
Partnerships for Public Health in India
Tracking Progress Towards
Sustainable Elimination of Iodine
Deficiency Disorders (IDD) in
Kerala and Tamil Nadu, India
Studies in Kerala, Tamil Nadu and Orissa, Bihar
Tamil Nadu
Orissa
Kerala
Bihar
The Kerala Study
Kerala
Kerala Study - Partners
1) Government of Kerala
2) Government Medical Colleges
3) State Nutrition Lab
4) IndiaCLEN
5) Indian Medical Association
6) ICCIDD
7) UNICEF, India
Process of Partnership
1) Enrollment of Stakeholders
2) Partnership & Planning
3) Partnership in Data Collection & Dissemination of result
4) Political Advocacy and Follow-up
May 2000
June 4th 2000
June 5th 2000
June 5th 2000
Advisory Committee Meeting
Meeting with Mr. Rajeev Sadanandan, Secretary Health,
Government of Kerala
Meeting with Prof. K Leelamoni,Dr. Rajamohanan, Dr. Vijayakumar
Dept. of Community Medicine,Medical College, Thiruvananthapuram
Meeting with Mrs. M S Subhadra,Directorate of Medical Education
Enro
lment o
f Sta
kehold
ers
Indian Medical Assn. & IndiaCLEN
Enrollment of Stakeholders
• Foundation: sound science
• Established coalitions (IndiaCLEN)
• New linkages (IMA)
• Meeting with highest policy makers (Secretary Health)
• Clarity of proposal
• Work ethics: A professional approach
June 2000
July – October 2000
October 24th & 25th 2000
November 29th 2000
UNICEF/ICCIDDas a stakeholder
Preparation of Draft ProtocolInteraction with Prof. Leelamoni,
Mr. Rajeev Sadanandan
Training & Orientation WorkshopProtocol Finalization
Debriefing WorkshopFinalization of field study schedule
Partn
ersh
ips a
nd
Pla
nnin
g
Capacity BuildingSense of Ownership
Joint EffortSense of Involvement
in the study
Training,Quality Assurance
Partnership & Planning
• Recognized international technical bodies: ICCIDD/ UNICEF
• Capacity Building: Key issues sorted out by state investigators themselves
• Sense of ownership of data: Own efforts
• Sense of involvement in the study
• Thorough training on all aspects of the survey
• Quality assurance: Training and application
January 2001
March 2001
April 29th 2001
Field Study(All Medical Colleges)
Laboratory Analysis (DHS)Data Analysis (Medical College,
Thiruvananthapuram)
Dissemination Workshop
Partn
ersh
ips in
Data
C
olle
ction &
D
issem
inatio
nCapacity Building
PartnershipSense of Ownership
Capacity BuildingPartnership
Sense of Ownership
Government (Central & State), Academia,NGOs, Experts, Nutritionists
Activists
June 2001
August 2001
May 2002
Meeting with Mr Ramesh Chennitala, MP from Kerala
Meeting with Mr A K Antony, Chief Minister of Kerala
Official release of the Kerala Report byMr P Sankaran, Health Minister of Kerala
Politica
l Ad
voca
cy a
nd
Fo
llow
up
Sensitization ofpolitical leadership
Sensitization ofpolitical leadership
Follow up Activities
Dissemination of Results, Political advocacy & Follow up
Dissemination
• Transparency: Protagonists and Antagonists of the USI strategy invited; Everyone’s views were considered
Follow-up
• Development, coordination and expansion of political influence
• Sensitization of the public
• Follow-up activities
• Regular feedback
• Catalytic role of credible agencies: UNICEF/ICCIDD
• A collaborative exercise: a joint effort
Criteria for Tracking Progress Towards Eliminating IDD As A Public Health
Problem
Indicator Goal Kerala
Thyroid size ( age group 6-12 years)Proportion with enlarged
thyroid (1067 subjects)
<5% 16.6%(95% CI - 14.4 – 18.8
%)
Median Urinary Iodine (µg/L)
(990 Subjects)> 100 123.3
( Range 10.2 - 378 g/L)
Salt iodisationProportion of Households
consuming adequately iodised salt
(1065 samples)
>90% 48.9%(95% CI - 45.9 – 51.9
%)
The Tamil Nadu Study
Tamil Nadu
A Collaborative Project BetweenDepartment of Public Health and Preventive Medicine,
Regional Health & Family Welfare Training Centres
Food Analysis Laboratories
Government Medical Colleges
Government of Tamil Nadu
National Institute of Epidemiology, ICMR, Chennai
National Institute of Nutrition, Hyderabad
India Clinical Epidemiology Network (IndiaCLEN)
All India Institute of Medical Sciences, New Delhi
The Micronutrient Initiative, New Delhi
Indian Coalition for Control of
Iodine Deficiency Disorders (ICCIDD)
United Nations Children’s Fund (UNICEF), Tamil Nadu
• Tamil Nadu 30 Clusters
IDD Study in Tamil Nadu - Objectives
1. To assess current status of IDD in Tamil Nadu
using WHO/UNICEF/ICCIDD Criteria
2. To determine availability and cost of
adequately iodised salt at the household level
in Tamil Nadu
3. To assess the community’s perception towards
IDD, salt & iodised salt in Tamil Nadu
Training Workshop at IPH, Poonamallee
28-30 November 2002
1) Training, Field Study, Laboratory Analysis: Department of Public Health and Preventive Medicine, Regional Health & Family Welfare Training Centres, Food Analysis Laboratories, Government Medical Colleges, Government of Tamil Nadu
2) Data Entry and Analysis: National Institute of Epidemiology, ICMR, Chennai
3) Laboratory Analysis and External Quality Assurance in Salt iodine analysis: National Institute of Nutrition, Hyderabad
Roles and Responsibilities - 1
4) The Qualitative Study: India Clinical Epidemiology Network (IndiaCLEN)
5) Overall Coordination, Technical Expertise: All India Institute of Medical Sciences, New Delhi, Indian Coalition for Control of Iodine Deficiency Disorders (ICCIDD)
6) Main Funding Agency: The Micronutrient Initiative, New Delhi
7) Additional Funding for Training & Dissemination: United Nations Children’s Fund (UNICEF), Tamil Nadu
Roles and Responsibilities - 2
Criteria for Tracking Progress Towards Eliminating IDD As A Public Health
Problem
Indicator Goal Tamil Nadu
Thyroid size ( age group 6-12 years)Proportion with enlarged
thyroid (1230 subjects)
<5% 13.5%(95% CI-11.6 – 15.4%)
Median Urinary Iodine (µg/L)
(1206 Subjects)
> 100 89.5( Range 2.0 – 422.1
g/L)
Salt iodisationProportion of Households
consuming adequately iodised salt
(1228 Samples)
>90% 18.2%(95% CI-16 – 20.4 %)
Dissemination Workshop5th June 2003
Organized by the Government of Tamil Nadu
Participants:
Government of Tamil Nadu & Its Agencies
Tamil Nadu Salt Corporation
National Institute of Epidemiology, ICMR, Chennai
National Institute of Nutrition, Hyderabad
All India Institute of Medical Sciences, New Delhi
IndiaCLEN
The Micronutrient Initiative, New Delhi
Indian Coalition for Control of
Iodine Deficiency Disorders (ICCIDD)
United Nations Children’s Fund (UNICEF), Tamil Nadu
Recommendations
• Establishment of an IDD Review Committee at the Department of Public Health & Preventive Medicine
• Awareness generation – In the community through television & radio– Grassroot level workers through the health
system
• Production level monitoring
• Cyclic monitoring
Tracking Progress Towards Sustaining Elimination of IDD in
Kerala
Tracking Progress Towards Sustaining Elimination of IDD in
Tamil Nadu
Dissemination Workshop5th June 2003
AdvocacyDemand Creation
Monitoring
Health Minister
Sec Health
Panchayat Raj Members
District Magistrates}
AwarenessMonitoring
Activities Related to Supply Side
Increase in Iodised Salt Production
Capacity of TNSC
Salt & Iodized Salt
Producers Meeting}
Ensuring Quality, Accessibility. Availability, Affordability, Acceptability
of Iodised Salt
The Tamil Nadu IDD Study and Follow Up Process
Success in Public Health
1) Well-defined research question
2) Sound scientific research protocol with qualitative and quantitative components
3) State specific information
4) Inter-disciplinary approach
5) Participatory approach
6) Partnership with private sector
7) Linking research with decision making process Mr. P Hota, Secretary to the Government of India, Department of Family Welfare,
Ministry of Health & Family Welfare