1. 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) Chandigarh 28 th – 29 th February 2004

2. 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

3. 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

4. Iterative Loop Research-Policy-Program POLICY RESEARCHPROGRAM 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

5. Iterative Loop Research-Policy-Program RESEARCH POLICY PROGRAM Partnerships

6. 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

7. Partnerships in Public Health

8. 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

9. 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 www.pitt.edu/~super1/

10. 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)

11. Partnerships for Public Health in India Tracking Progress Towards Sustainable Elimination of Iodine Deficiency Disorders (IDD) in Kerala and Tamil Nadu, India

12. Studies in Kerala, Tamil Nadu and Orissa, Bihar Tamil Nadu Orissa Kerala Bihar

13. The Kerala Study Kerala

14. 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

15. Process of Partnership 1)Enrollment of Stakeholders 2)Partnership & Planning 3)Partnership in Data Collection & Dissemination of result 4)Political Advocacy and Follow-up

16. May 2000 June 4 th 2000 June 5 th 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 Enrolment of Stakeholders Indian Medical Assn. & IndiaCLEN

17. 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

18. June 2000 July – October 2000 October 24 th & 25th 2000 November 29 th 2000 UNICEF/ICCIDD as a stakeholder Preparation of Draft Protocol Interaction with Prof. Leelamoni, Mr. Rajeev Sadanandan Training & Orientation Workshop Protocol Finalization Debriefing Workshop Finalization of field study schedule Partnerships and Planning Capacity Building Sense of Ownership Joint Effort Sense of Involvement in the study Training, Quality Assurance

19. 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

20. January 2001 March 2001 April 29 th 2001 Field Study (All Medical Colleges) Laboratory Analysis (DHS) Data Analysis (Medical College, Thiruvananthapuram) Dissemination Workshop Partnerships in Data Collection & Dissemination Capacity Building Partnership Sense of Ownership Capacity Building Partnership Sense of Ownership Government (Central & State), Academia,NGOs, Experts, Nutritionists Activists

21. 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 by Mr P Sankaran, Health Minister of Kerala Political Advocacy and Follow up Sensitization of political leadership Sensitization of political leadership Follow up Activities

22. 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

23. Criteria for Tracking Progress Towards Eliminating IDD As A Public Health Problem IndicatorGoalKerala 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)> 100123.3 ( Range 10.2 - 378  g/L) Salt iodisation Proportion of Households consuming adequately iodised salt (1065 samples) >90% 48.9% (95% CI - 45.9 – 51.9 %)

24. The Tamil Nadu Study Tamil Nadu

25. A Collaborative Project Between Department 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

26. Tamil Nadu 30 Clusters

27. 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

28. Training Workshop at IPH, Poonamallee 28-30 November 2002

29. 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

30. 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

31. Criteria for Tracking Progress Towards Eliminating IDD As A Public Health Problem IndicatorGoalTamil 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) > 10089.5 ( Range 2.0 – 422.1  g/L) Salt iodisation Proportion of Households consuming adequately iodised salt (1228 Samples) >90%18.2% (95% CI-16 – 20.4 %)

32. Dissemination Workshop 5 th 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

34. 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

35. Tracking Progress Towards Sustaining Elimination of IDD in Kerala Tracking Progress Towards Sustaining Elimination of IDD in Tamil Nadu Dissemination Workshop 5 th June 2003 Advocacy Demand Creation Monitoring Health Minister Sec Health Panchayat Raj Members District Magistrates } Awareness Monitoring 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

36. 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