To Overcome IDD : Indonesian Experience Triono Soendoro Ministry of Health

1.1979: M.D. (Airlangga Medical School, Indon) : M.Sc, M.Phil, Ph.D, Yale Univ, USA : Director Health & Nutrition, Bappenas : Leadership Fellow at the Gates Institute, University of Johns Hopkins, USA : Secretary of Decentralization Unit and Policy Advisory Group to MoH; now: Senior Associate, Bill and Melinda Gates Institute, Johns Hopkins University, USA : Director General of NIH-RD, MoH; –now: Senior Advisor to MoH now: Faculty Member of O/G, Reproductive Endocrinology, Med Sch Udayana Univ, Bali now: Visitng lecturer at several universities : Assist Indon President to Post MDG 2015

Outline 1.Setting the Objectives 2.Assessing IDD Progress 3.The Challenges 4.The Way forward

Outline 1.Setting the Objectives 2.Assessing IDD Progress 3.The Challenges 4.The Way forward

The Objectives 1.To increase the national coverage of adequate iodized salt consumption at household level 2.To sustain the coverage of adequate iodized salt consumption in all districts 5

Outline 1.Setting the Objectives 2.Assessing IDD Progress* 3.The Challenges 4.The Way forward

Assessing IDD Progress IDD surveys: 93, 96/98, ‘03 (TGR, UIE) HH’s Iodized Salt: – CBS (Susenas ), – MOH (Riskesdas ) Urinary Iodine Excretion (UIE): – Riskesdas 2007 (sub-samples in 30 districts)

IDD Survey: ‘93, ’96/’98, & ‘03 Design‘93 surveyBaseline (96/98)Evaluation (‘03) Province52728 District/City Sub-district Cluster Primary school 60 in every province3 in every sub-district25 in every district Palpation of thyroid gland enlargement School children 6-10School children 6-12School children 8-10 Pregnant women <35 School childrenPregnant womenSchool children Urine sample for urinary iodine level Analysis urine sample: wet acid digestion method using potassium chlorate Analysis urine sample: wet acid digestion method using ammonium persulfate Pregnant womenPregnant women (in 2 provinces) -

Progress: IDD Elimination/TGR Note: Only sub-districts included within the 80/82 sample frame were included from the 96/98 sample for comparison

Progress: IDD Elimination/TGR

The Changes: District Endemicity Endemicity District/City 96/9803 CategoryTGRN%N% Non-endemic< 5.0% Mild endemic5.0 – 19.9% Moderate endemic 20.0 – 29.9% Severe endemic>= 30% T o t a l

Changes: 268 District Endemicity Endemicity District/City 1996/ CategoryTGRN%N% Non-endemic < 5.0% Mild endemic 5.0 – 19.9% Mod- endemic 20.0 – 29.9% Sev- endemic >= 30% T o t a l

Distribution of Province by Category of Endemicity in ’96/’98 and ‘03 Endemicity Province 1996/ CategoryTGRN%N% Non-endemic< 5.0% Mild endemic5.0 – 19.9% Moderate endemic20.0 – 29.9% Severe endemic >= 30% T o t a l

Trend of HH’s Iodized Salt Consumption: Source: Susenas , Riskesdas 2007

% HH Consume Iodized Salt:

A ssociation between UIE and Iodized Salt Coverage 18 Source IDD Survey 2003

H H’s Iodized Salt vs Iodine Urine (School Age Children) Iodized Salt (ppm)UIE ug/L <57,8%<200, ,4%20-503, ,6% , ,7% , ,5%**>300 *) 21,9 *) Source: Riskesdas 2007 (30 Districts) *) Excessive:

Outline 1.Setting the Objectives 2.Assessing IDD Progress 3.The Challenges* 4.The Way forward

The Challenges Universal Salt Iodization (USI) targets have not been met nationally, but excessive iodine intake is beginning to manifest Focus of USI should be directed to Provinces/Districts with HH’s consume Iodized salt <50% Attention is also needed for areas where the UIE level >300 ug/L Health disparities*: PHDI

The Purpose: PHDI Describe public health development progress for entire districts in Indonesia Focused programs interventions (local specific) in each districts.

PHDI Progress: ‘07-’10 (‘13) Composite PHDI (7 Indicator): Malnutr, Stunring, Imuniz ANC/MCH, Sanitation, Water

The Benefits A tool to evaluate the process of improving a certain area (district/municipality) on health status over time. An advocacy for province and district government to increase their health status using focused resources and programs interventions priority. As a criteria of health fund allocation from central to province and district government.

District DBK: The Areas Category District/Urban DBK District/Urban Non DBK Jumlah440497

P-DBK: 10 Prov as of ‘11  Aceh (14/21)  NTB( 6/9)  NTT(11/16)  Sulteng(7/10)  Sultra(8/10)  Gorontl(5/5)  Sulbar (4/5)  Maluku(5/8)  Pap Bar(6/9)  Papua(14/20) Prop DBK: # total : 28 prop130 kab/kot Prop > 50% Kab DBK : 10 prop* 80 kab/kot Prop < 50% Kab DBK : 18 prop 50 kab/kot

27 Sumber : Riskesdas 2007

Training Actions Organizational Change Start End Actions RDS Trans lation Internal Support Group Mentoring Learning History: Cohort of PDBK The Challenges: Partnership

Comitment & Involvement

District Gorontalo (2011) sejumlah

The Way Forward Increase knowledge and awareness of the population Establish a proper surveillance system Ensuring sustainability Conduct national survey to track progress

The Way Forward (2) It tells us “WHAT It tells us “PROBLEM” But it does not tell us “HOW? Left us with: ‘ISSUES, UNCERTAINTIES, and ‘HOPES’ Action Non Material Approach