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Consultant’s Report
Project Number: JFPR 9005 and 9052
September 2009
Promoting Universal Salt Iodization
in Central Asia and Mongolia, 2001–2007
Experiences of Japan Fund for Poverty Reduction (JFPR)
JFPR9005 and JFPR9052
Prepared by Frits van der Haar, PhD
Visiting Associate Professor
Hubert Department of Global Health
Rollins School of Public Health
Emory University
Atlanta, GA, USA
ABBREVIATIONS
ADB – Asian Development Bank
CDC – Centers for Disease Control and Prevention
CIP – Country Investment Plan
CoC – Certification of Conformity
CPO – Country Project Office
DALY – disability-adjusted life year
DHS – Demographic Health Survey
DMC – developing member countries
EA – Executive Agency
ECO – Economic Cooperation Organization
GAIN – Global Alliance for Improved Nutrition
GBAO – Gorno-Badakhshan Autonomous Oblast
GDP – gross domestic product
GOST – common product standard (GOST)
HACCP – Hazard Analysis and Critical Control Point
ICCIDD – International Council for the Control of Iodine Deficiency
IDD – iodine deficiency disorder
IMF – International Monetary Fund
ISO – International Organization for Standardization
JICA – Japan International Cooperation Agency
JFPR – Japan Fund for Poverty Reduction
KAN – Kazakh Academy of Nutrition
KASP – Kyrgyz Association of Salt Producers
KAP – knowledge, attitudes and practices
LGPBK – League of Grain Processors and Bakeries in Kazakhstan
LoA – Letter of Agreement
MICS – Multiple Indicator Cluster Survey
MDG – Millennium Development Goals
MPR – Mongolian People's Republic
MTR – Mid-Term Review
NSMA – National Salt Manufacturers Association
NTD – neural tube defect
RCAO – regional coordination and administrative office
RETA – regional technical assistance
RSES – Republican Sanitary-epidemiologic Station
SES – Sanitary Epidemiological Service
SSA – Salt Situation Analysis
SSIA – State Specialized Inspection Agency
TAIG – Technical and Implementation Group
TSH – thyrotropin
UI – urinary iodine
UN – United Nations
UNICEF – United Nations Children's Fund
US – Ultrasound
USAID-OMNI – U.S. Agency for International Development; Opportunities for
Micronutrient Interventions
USI – Universal Salt Iodization
USSR – United Soviet Socialist Republic
WCBA – Women of child-bearing age
WHO – World Health Organization
WTO – World Trade Organization
WYD – Chinese abbreviation for a single-beam spectrophotometer for
measuring salt iodine content
This consultant’s report does not necessarily reflect the views of ADB or the Government
concerned, and ADB and the Government cannot be held liable for its contents.
CONTENTS
Page
I. INTRODUCTION 1
A. Rationale for Investing in Food Fortification 1
B. Involvement by the Asian Development Bank in Poverty Reduction 3
II. A HISTORICAL PERSPECTIVE 4
A. Period until 1990 in Central Asia and Mongolia 4
B. The Decade of the 1990s 6
C. Some Noteworthy Experiences and Lessons Learned 12
D. End-of-1990s-Decade Status of Salt Iodization 14
E. Preparations for the Almaty Forum 2001 18
III. THE ALMATY FORUM 2001 21
A. Short Outline of the JFPR9005 Project 21
B. Progress in implementing JFPR9005 22
C. Stimulating USI during the JFPR9005 period 23
D. Advocacy, communications and social mobilization: Mini Round Table in
Bishkek, February 2002 30
E. Legislation and regulation: Mini Round Table in Tashkent, June 2002 32
F. Mid-Term Review, October 2002 34
G. The second period of JFPR9005: October 2002–September 2004 35
H. JFPR Project Implementation: Mini-Round Table in Bishkek, April 2003 41
I. JFPR9005 Strategy implementation 43
J. Iodized Salt Production: Mini Round Table in Bishkek, July 2004 47
K. Completion of JFPR9005 and initiation of JFPR9052 48
L. Stocktaking in preparation for the Almaty Forum 2004 49
IV. THE ALMATY FORUM 2004 52
A. Short outline of the JFPR9052 project 52
B. Progress in implementing JFPR9052 53
C. Sustainable Quality Salt Iodization: Mini Round Table in Tashkent, November
2005 53
D. Mid-Term JFPR9052 Project Review, Cholpon Ata, September 2006 54
E. Kazakhstan 57
F. Kyrgyz Republic 63
G. Mongolia 64
H. Tajikistan 67
I. Uzbekistan 69
J. Stocktaking in preparation for the Almaty Forum 2007 70
V. THE ALMATY FORUM 2007 81
VI. LESSONS LEARNED 82
A. The conceptual approach 82
B. Implementation 84
C. Conclusion 87
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APPENDIXES
1. JFPR 9005: ADB/UNICEF/KAN A Salt Situational Analysis 90
2. JFPR-TA 9005 Additional Guidance on the Design of Country Proposals 94
3. ALMATY FORUM 2001 99
4. First Regional Workshop of Salt Producers of Central Asia: Decisions and
Recommendations 102
5. Almaty Forum 2004 104
6. Second Regional Meeting of Salt Producers: Quality Salt Iodization in Central Asia and
Mongolia 109
7. Almaty Forum 2007 111
I. INTRODUCTION
A. Rationale for Investing in Food Fortification
1. The human body needs tiny amounts of vitamins and minerals in the daily diet for
healthy growth, steady development and optimal function. Research and surveys during the
past decades have shown that these micronutrients are often not available in sufficient amounts
from the common diets of the populations in Central Asia. Lessons drawn from development
programs of the 2nd half of the last century indicate that eliminating the dietary shortfalls in the
key micronutrients iron, folic acid, iodine and zinc is a health, social and economic development
bargain because of their hugely beneficial effects on reducing disease prevalence and severity
as well as improving intelligence and productivity.
2. The major forms of micronutrient malnutrition are iron deficiency, iodine deficiency
disorders (IDD) and vitamin A deficiency, and during the past few years, also the developmental
importance of folic acid and zinc deficiencies have become recognized. Iodine deficiency is the
single most important cause of irreversible mental retardation in the world. It causes cretinism,
goiter, intellectual indolence and physical lethargy in affected individuals. Iron deficiency impairs
the cognitive development of young children and reduces the work productivity of manual
laborers. Being the main cause of anemia, iron deficiency in pregnant women is a major
preventable underlying cause of maternal reproductive mortality. The likelihood that a woman
delivers a newborn baby with a severe birth defect, involving the brain (anencephaly) or spinal
cord (Spina Bifida), commonly known as “neural tube defects” (NTD), increases dramatically if
her diet lacks sufficient folate. Half of the babies born with a NTD die within 24h after delivery,
the other half need to undergo reconstructive surgery, often several times. It is estimated that
worldwide, 300-500,000 newborns per year are delivered with a NTD caused by maternal
dietary folic acid deficiency.
3. The overt health outcomes in affected individuals, such as goiter, anemia, NTD and
childhood or maternal death, are only the “tip of an iceberg.” Due to lower intelligence, reduced
energy, impaired disease resistance and stunted growth, whole populations affected by
micronutrient deficiencies are unable to achieve their full mental and physical potential as
citizens, workers and parents. High rates of malnutrition in the population imply higher budget
needs for health services to treat preventable disease and they lead to loss of gross domestic
product (GDP) as a result of diminished productivity of the adult workforce. Malnutrition is the
underlying cause of more than half of all child deaths in the world, and in more than 80 percent
of these deaths, the children’s nutritional status is mildly or moderately, rather than severely
compromised. Iron deficiency in adults causes an average loss of 0.2 percent GDP in low and
middle income countries. When adding the damage of iron deficiency to the cognitive and motor
development in children, the projected economic loss to a country may leap to as high as 1–1.5
percent of GDP. On average, iodine deficiency reduces a schoolchild’s IQ by 13.5 points while
stunting reduces it by 8 points. The treatment cost in Western countries over the first 10 years of
a newborn surviving with NTD has been estimated to be at least US$80,000.
4. Improving nutrition is, therefore, as much an issue of economics and poverty alleviation
as it is one of people’s health and welfare, social equity and human rights. The key to fully
appreciating the health, social and economic development bargain of eliminating micronutrient
malnutrition is in the realization that the problem is not only debilitating, widespread and
expensive but also that the costs of addressing it are small and the benefits dramatic. Alleviating
malnutrition among young growing children reduces mortality, but it also leads to higher school
completion rates and better learning outcomes among the survivors, thus improving their future
2
wage earnings. For example, a 1 percent increase in child height has been associated with a 4
percent increase in total lifetime wages. Eliminating anemia would contribute 5–17 percent
increase in lifetime earnings, adding 2 percent of GDP in the most affected countries. The World
Bank has projected that preventing micronutrient malnutrition in India and China would raise
each country’s GDP by at least US$2.5 billion a year.
5. The micronutrient problem cannot be solved through strengthening of the health care
delivery systems and alleviation of poverty through stimulating people’s incomes alone.
Although poorer families are usually more affected, the vitamin and mineral content is a hidden
value in food and, therefore, consumers do not automatically prefer micronutrient-richer foods
with increasing income. Also, the signs and symptoms that someone has eaten too little of a
particular vitamin or mineral are subtle and often delayed, and they may not be perceived as
being caused by the common diet even by the health profession. Moreover, some vitamins and
minerals are concentrated in a meaningful amount in a few foods only and therefore, just eating
more of the same diet or a more varied diet does not always lead to the desired increased
vitamin or mineral intake. A case in point is iodine: Since the iodine content in foods is a direct
reflection of its concentration in the soil on which the food was produced, iodine deficiency
cannot be addressed by dietary change without adding it to a common food, such as salt.
6. Cost-effective interventions to alleviate micronutrient malnutrition are time-tested and
available. In assessments of investments to improve the health status of populations based on
cost per disability-adjusted life years (DALY), the elimination of micronutrient malnutrition
compares favorably to other health interventions. Already in 1993 a World Bank publication
stated: “No other technology offers as large an opportunity to improve lives and accelerate
development at such low cost and in such a short time”. In 2004, when asked how they would
allocate $50billion for development, a panel of leading economists, including 3 Nobel Laureates,
ranked the provision of micronutrients second only to combating HIV/AIDS. Estimated
cost/benefits of iron programs are in the range of 1:176-200 for fortification and 1:6-14 for
supplementation during pregnancy, thus making for better investments on a direct comparative
basis than trade liberalization, reduction of migration barriers, new agricultural technologies,
water and sanitation, and amelioration of climate change.
7. An illustration of the macro-scale economic impact of micronutrient malnutrition in a
number of low-income Asian nations was presented at the ADB-sponsored Forum on Food
Fortification held in Manila, the Philippines, in February 2000. The estimates focused mainly on
the most populous South Asian countries. By refining the data and extending them to include
also the emerging economies of Central Asia, ADB in 2005 estimated that existing micronutrient
malnutrition had impacts on the national economies in the order of 0.8 to 1.2 percent GDP.
8. Successes from investments in reducing micronutrient malnutrition contribute toward
achieving the Millennium Development Goals (MDG). By stimulating physical and intellectual
capacity, iron and iodine-improved diets contribute to MDG 1: Eradication of extreme poverty
and hunger. Child stunting is reduced by eliminating iodine and zinc deficiency, thus contributing
to better child growth and reducing the “non-income-poverty” dimension of MDG 1. The
alleviation of anemia related to iron deficiency contributes to MDG 2: Universal primary
education, from better cognition and lesser drop-out from school. The achievement of the child
mortality (MDG 4) and maternal health (MDG 5) goals will benefit from improved iron, iodine,
zinc and folate consumption by populations via impacts on infant and child immunity, fetal brain
formation and maternal reproductive survival. Finally, sharing information and public progress
reporting – two key features of oversight and support to national micronutrient programs - are
3
powerful drivers for national and global multi-sector coalitions, thus contributing to achieving
MDG 8: Partnerships for development.
B. Involvement by the Asian Development Bank in Poverty Reduction
9. The Asian Development Bank collaborates with the Governments of Developing Member
Countries (DMC) in Asia and the Pacific to assist in promoting vibrant economies that assure
the health and wellbeing of their populations. The over-arching goal of the work by ADB is
poverty alleviation. Notably, a definition of impoverishment used by ADB’s President offers a
powerful argument for the centrality of nutrition:
“Poverty is characterized by a lack of access to essential goods, services,
assets, and opportunities to which every human being is entitled. Everyone
should be free from hunger, should be able to live in peace, and should have
access to basic education and primary health care services“
10. Starting out from a joint analysis with United Nations Children's Fund (UNICEF) of
experiences in South and East Asian DMCs about how nutrition improves, and how additional
resources may be applied to reach the goals agreed-upon at the World Summit for Children,
ADB in early 2000 collaborated with the Micronutrient Initiative and the International Life
Sciences Institute in staging a 4-day forum on the use of food fortification as a way to address
the shortages of essential vitamins and minerals in the diets of Asian populations. Uniquely at
this Manila Forum, the 76 participants from 8 DMCs and associated technical agencies,
universities and UN organizations hailed from the broad spectrum of health, government and
food industry organizations. The assembled audience together mirrored half the world’s
population and, notably, three-fourths of those who suffered of micronutrient deficiencies in the
world. The Manila Forum’s Declaration drew conclusions of experience, and formulated an over-
arching principle for future Asian Development Bank (ADB) action to address the nutrition
problems in Asia through food fortification, namely:
(i) A multi-sector collaborative approach in pursuit of stimulating fortified food production,
supply and consumption in the population;
(ii) Open channels of communication to ensure fruitful dialogue and partnership at the highest
national level; and
(iii) A joint agency group effort through a regional technical assistance (RETA) facility at ADB
that would take the process forward toward detailed national plans.
11. Applied to Central Asia, the preparatory work and negotiations that led to the JFPR9005
project for “Improved Nutrition for Poor Mothers and Children in Asian Countries in Transition”
took place following the publication by ADB of its poverty reduction strategy in 1999, which was
comprised of 3 pillars: Pro-poor sustainable economic growth, inclusive social development, and
good governance. Also in 1999, ADB issued a Policy for the Health Sector paper that focused
on improving the health of the poor, women and children and encouraging DMCs to take an
active role in facilitating private sector involvement in health. Since the poorer sections of
societies are disproportionately affected by malnutrition and their inclusion in economic and
social development contributes greatly to sustained democratic systems, improved nutrition had
become a more obvious option for action under the new ADB poverty reduction and health
strategies.
12. In April-May 2000, the Government of Japan and ADB entered into an agreement to
establish the Japan Fund for Poverty Reduction (JFPR) within ADB, with the overall objective to
4
provide grants in support of innovative poverty-reduction and social development activities to
help alleviate poverty in DMCs. During the remainder of 2000, initial agreements were obtained
in Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan and the Republic of Uzbekistan for their
collaboration in a regional food fortification project to address the causes of micronutrient
deficiencies that had become structural characteristics of their national economies. The overall
objective of the project would be to pilot an umbrella regional program for delivering
micronutrient-fortified salt and wheat flour to the country’s populations, particularly targeted
toward poor children and women of reproductive age.
II. A HISTORICAL PERSPECTIVE 1
A. Period until 1990 in Central Asia and Mongolia
13. In the former United Soviet Socialist Republic (USSR), the action to address iodine
deficiency was for almost forty years governed by the Ordinance of the Ministry of Health in
Moscow №.37-M, dated 14 February 1956, and entitled “On Improvement of Measures to Fight
Endemic Goitre”. This regulation defined the Regions in the USSR with a high prevalence of
endemic goiter where iodized salt should be supplied and formed the legal basis for the
establishment of Anti-Goitre Dispensaries unified under a central Anti-Goitre Commission in
Moscow and Anti-Goitre Committees in each of the listed Regions under their respective
Republican Ministries of Health. The Ordinance also specified the personnel and training needs
for the Anti-Goitre Dispensaries, defined the coordination with and support needed from other
government entities (the Ministries of Trade, Medical Industry and Food Industry, and the State
Supply Committee, State Planning Committee and so on), and it made the Sanitary-Hygienic
Stations of the Ministry of Health responsible for inspections of the iodized salt market supplies.
The majority of Regions and administrative divisions of the Kazakh, Kirghiz, Tajik and Uzbek
Soviet Republics were listed as affected by endemic goiter 2 . To add to the Institute of
Endocrinology already established in Tashkent, Anti-Goitre Dispensaries were created in
Shymkent, Bishkek and Dushanbe. The supply of iodized salt became mandatory while the
trade in non-iodized salt was generally restricted. The amount of iodized salt for each Region
was defined by the State Planning and Supply Committees of the USSR Government and
supplied on requests by officials of the Ministry of Trade in all Union Republics for retail salt and
the Ministry of Food Industry and Fisheries for food-grade salt.
14. Iodized salt production in the USSR after the 2nd World War was promoted mainly
through large-scale enterprises under the Ministry of Food Industry, located first in Russia and
Ukraine and from the mid 1950s onward, also in Kazakhstan and other Republics. The Salt
Industry Research and Development Institute in Ukraine devised machinery for salt harvesting,
washing and processing that found their application throughout the Republics. Potassium iodide
used for iodization was readily available from underground sources in Azerbaijan, Russia,
Turkmenistan and Ukraine. To produce iodized salt, each salt enterprise was given an annual
plan, which for all practical purposes had the power of law. The production needs for iodized
salt in the Soviet Union during the 1960s and 1970s were set at 4.5-5 kg/person/y. At that time,
the production of iodized salt and the targeting to Regions where endemic goiter occurred was a
matter of high government concern and vigorous attention. Data from a personal archive kept by
the President of the Association of Russian Salt Producers indicate that the total supply of
1
The author is grateful to Professor G Gerasimov of UNICEF Moscow for access to the following report: Iodine
Deficiency Disorders (IDD) in the Russian Federation. A Review of Policies towards IDD Prevention and Control
and Trends in IDD Epidemiology (1950-2002). Published in Russian, 2002.
2
By early 1980, the “List of Endemic Goiter Regions of the USSR that require Iodized Salt Supply” contained 30 of
the 41 administrative divisions in the Kazakh, Kirghiz, Tajik and Uzbek Soviet Republics.
5
iodized salt in the USSR increased from approx. 100,000 to almost 1,000,000 ton between 1950
and 1965.
15. The Ordinance of 1954 also mandated State-financed distribution of iodine tablets to
high risk groups of pregnant and breastfeeding women, and to young children and adolescents.
During the early 1950s, several pharmaceutical enterprises began producing KI tablets called
“Antistrumin”, which contained 1mg of potassium iodide. Supplements were distributed (1 tablet
weekly) in schools and kindergartens and provided on a routine basis to pregnant and
breastfeeding women in prenatal clinics and maternities. A geological chemistry survey of the
whole USSR territory was produced in the mid 1960s with a map of areas where the iodine
content in soil and water was lowest and these areas were put under even stricter control in
terms of the mandatory supply with iodized salt.
16. Following the Ordinance, two country-wide surveys of Endemic Goiter were carried out
in the USSR, performed primarily by teams operating from the 63 special Anti-Goitre
Dispensaries established all over the USSR. Detailed information about the epidemiological
design of the surveys is lacking, but it is likely that they were aimed at goiter assessments of
large numbers of people obtained from the general population without specific selection criteria.
A 1st survey in 1965 reported of a total of 13,238,428 persons. The national cumulative
prevalence of goiters grade 1 to 5 was 6.24 percent, nodular goiter was 0.16 percent and
medical treatment was recommended for 1.08 percent of all surveyed people. During a 2nd
survey in 1969, an even larger number of people were assessed for their goiter, namely
30,119,542 persons. Grades 1-5 goiters had fallen to 4.98 percent, nodular goiter to 0.07
percent and medical treatment was recommended to 0.66 percent of those surveyed. Thus,
despite the comparatively low prevalence of endemic goiter observed after the Ordinance had
been put into effect for a decade, the prevalence of endemic and nodular goiter again
decreased sizably during the subsequent 4-year period. The reduction was attributed to the
tightening of the measures aimed at control and prevention, in particular the significant increase
in production and supply of iodized salt for consumption by the population.
17. By the early 1970s, therefore, the burden of iodine deficiency in the USSR had been
significantly ameliorated. The occurrence of small-size goiters had decreased to a sporadic
level, big-sized goiters had been virtually eliminated and new cases of endemic cretinism were
no longer observed. On this basis, endemic goiter was officially declared as a problem that had
been overcome, goiter monitoring was ceased at the national and regional levels and the
special medical form, used for registering endemic goiter cases, was abolished. The activities of
the Anti-Goitre Dispensaries were to continue but the results of their work were no longer
required to be reported to Ministries of Health of the Soviet Republics and the central USSR
authorities. Thus, national oversight of IDD control was abandoned and any future change was
not consolidated by central review, decision and follow-up.
18. The industry standard in the USSR required the use of potassium iodide at a relatively
low level of 23±11 mg iodine per kg salt. Increasingly with time, however, the aging technologies
and ordinary QA methods in salt enterprises became less capable to achieve this range.
Moreover, due to the instability of KI and high loss of iodine with poor packaging and long
supply lines, the quality of iodized salt supplies in retail outlets started falling and by the mid
1980s, sanitary-hygiene stations of the Republics increasingly reported findings of low quality of
iodized salt. In 1986 for example, adequate iodine content was found in 57 percent of salt
samples measured in Kazakhstan and only 10 percent in Belarus and 3 percent in Azerbaijan.
Importantly, 19 percent, 5 percent and 35 percent of the salt samples in these Republics,
respectively, were reported to contain no iodine. At about the same time, also the amount of
6
iodized salt production had started to decrease, along with the overall decline in the centralized
Soviet economy. By 1990, the production of iodized salt was at a level of 56 percent of the
planned amount of 1.4 million tons.
19. The USSR Ministry of Health during the years 1986-1989 transformed the Anti-Goitre
Dispensaries into Endocrinology Dispensaries, and widened their orientation from the treatment
and control of endemic goiter to diagnosis and treatment of endocrine conditions, primarily
diabetes. Although no extra resources were provided to meet these goals, the Center’s primary
orientation, i.e. control measures and monitoring of iodine deficiency in the population, was
increasingly being lost. After the Chernobyl Nuclear Power Station meltdown in 1986 which
emitted a large amount of radioactive iodine into vast areas of Russia, Ukraine and Belarus,
however, the interest in the iodine situation in the population of the USSR started to return
somewhat by the end of the 1980s. In 1990, the All-Union Endocrinology Research Centre in
Moscow (now the Endocrinology Research Centre of the Russian Academy of Medical
Sciences), in collaboration with the USSR Ministry of Health and the USSR Statistical
Committee, organized a large-scale survey to assess goiter prevalence and morbidity. The
medical registration form for cases of goiter was temporarily re-instated for 1 year, allowing
results to be obtained from eleven of the fifteen Union Republics. Unfortunately, the report of
this survey has never been published, probably due to the termination of all the USSR
government ministries in 1991-1992. It is at present impossible to get more detailed information
about the epidemiological design of this survey. The survey recorded 1,044,767 persons with
goiter in 1990, a marked rise over the 1969 figure. Of this number, 76,305 had visible goiter and
81,495 had nodular goiter. In some Soviet Regions the number of records of patients had
increased by 24 to 177% between 1988 and 1990. However, due to the political and economical
turmoil in Russia and the Union Republics during the early 1990s, this information did not attract
the attention deserved in government circles.
20. The Mongolian People’s Republic (MPR) had formalized relations with the USSR
already from before World War II, reflecting the predominant communist policy and a
passionate, long-standing desire for autonomy especially from imperialist China. In the summer
of 1939, the Mongolians repelled the invading Japanese troops at the border with Manchuria
with support of the Soviets. China officially recognized the MPR in 1945 and a pact between the
USSR and China in 1950 guaranteed Mongolia’s independence. In June 1964, the MPR and the
Soviet Union signed another 20-year treaty of friendship, cooperation and mutual assistance but
the programmed activities to combat iodine deficiency, actively promoted in the USSR during
the 1950s and 1960s were not emulated by a similar policy in Mongolia. Salt was considered an
essential commodity at that time and the Government started providing subsidies for local salt
producers to ease the living conditions of the urban population. The population at that time
numbered about 2 million, the larger part of which was rural and mostly nomadic although
urbanization had started to increase. The landscape of Mongolia offers many natural salt
deposits that have been used since time immemorial for collecting salt for human and animal
consumption, as well as other common uses such as preparation of leather and preservation of
meat. Yet, the import of better quality salt, for example from the large vacuum-evaporation
Sibsol Company in Irkutsk, Siberia, must have provided a significant share of the salt consumed
in Mongolia already, certainly in the cities and townships of the North and Ulaan Baatar.
B. The Decade of the 1990s
21. On 29-30 September 1990 at the United Nations (UN) in New York, the largest gathering
of Heads of State and Government ever assembled at the World Summit for Children and
pledged their nations’ support to pursue an ambitious set of social development goals, including
7
the “virtual elimination of IDDs” and “one-third reduction of iron-deficiency anemia” by the year
2000. Sponsored by the Government of Canada, a Conference on Hidden Hunger in Montreal in
1991 took stock of the experiences of existing micronutrient programs in a diverse selection of
countries, and the International Conference on Nutrition in Rome in 1992 articulated the key
elements and actions that would amount to effective national strategies to tackle micronutrient
malnutrition in the population. This staged succession of 3 international gatherings set the stage
for an unprecedented global effort to rid the world from the age-old scourge of IDD. Underlying
the general conviction that global IDD elimination is an achievable goal was not just the
realization that the IDD problem was widespread and affected a majority of the world’s
populations, but also that large-scale, cost-effective ways to overcome iodine deficiency were
known and available, and that they could readily be mobilized in the majority of nations.
22. The consensus strategy for reaching virtual IDD elimination in each nation became
“Universal Salt Iodization” (USI), defined as “the iodization of all salt for human and animal
consumption, including the salt used in the food industry”. The choice for USI was articulated in
an agreement by the Joint UNICEF-World Health Organization (WHO) Committee on Health
Policy and published in 1994. The traditional approach in many countries until that time
consisted of large-scale, targeted provision of an iodine supplement, such as iodized oil
injections, capsules and/or KI tablets, which was often combined with an effort to mobilize salt
industry to increase its supply of iodized salt for consumers.
23. The message of the imperative to pursue and achieve USI as the principle strategy to
combat IDD also reached into Central Asia and Mongolia. From the presentations delivered by
Soviet scientists at an international symposium organized by International Council for the
Control of Iodine Deficiency (ICCIDD), WHO and UNICEF in Tashkent, Uzbekistan on 18-22
November 1991, it had become even more obvious that IDD had re-emerged as a significant
public health threat in the Soviet Union. Along with academicians of 8 other USSR Republics,
Kazakh and Uzbek experts presented data in Tashkent of hitherto unknown surveys of goiter
prevalence, urinary iodine excretion as well as thyroid hormone levels in newborns and young
children to demonstrate that after the Soviet Ordinance had been neglected in the early 1970s,
IDD had made a comeback during the previous decade in a broad array of regions and
population groups.
24. A Joint Workshop of multi-sector delegations from 10 countries under a newly formed
Economic Cooperation Organization (ECO) in Ashgabad, Turkmenistan on 15-16 June 1994
signified the earliest effort to stimulate senior-level Government action to reverse the
deteriorating situation in Central Asia. In each of the countries, “quick and dirty” assessments
were conducted as input into national review papers on the IDD situation prepared for the
Ashgabad workshop by local experts with support of ICCIDD, UNICEF, WHO, U.S. Agency for
International Development–Opportunities for Micronutrient Interventions (USAID-OMNI) and
Micronutrient Initiative consultants with expertise in IDD and salt industry. The 10
recommendations of the Workshop Declaration clearly articulated the need in each country to
ensure universal iodization of the salt supply, adoption of a multi-sector approach with a major
role to the salt industry along with the health development systems, and establishment of
communications, marketing efforts and enforcement systems, accompanied by regular
monitoring of the progress made toward the goal of eliminating IDD.
8
Figure 1: Loose Salt on Sale to Consumers in a Market of Tajikistan, Mid 1990s
1. Mongolia
25. In Mongolia, discussions of IDD and its elimination had also started during the early
1990s in response to the World Summit for Children. In May 1993, an inter-ministerial team
produced a National Action Plan for Children and in the fall of the same year, a nation-wide
survey was organized to assess the IDD burden in the resident population of the Aimags
(Provinces) and other administrative divisions of the vast territory. The overall prevalence of
goiter among 48,869 children aged 7-14 was 29.2%, of which 27.5% was palpable and 1.7%
visible. The goiter prevalence was below 10% in only 2 of the 22 Aimags in total, while the
prevalence in 17 was greater than 20% and in 7 above 30%, including Ulaan Baatar, the
Capital, with 42.3%. The results of goiter assessments among 10,900 women were very similar,
with a total goiter rate of 31.2% of which 2.8% was visible. These results were evidence enough
for the Minister of Health to propose that all the salt intended for humans and animals should be
iodized, a measure that was being resisted by some influential scientists who were not
convinced that the survey results signified iodine deficiency and questioned the value of
additional iodine supply for the wellbeing of children in Mongolia. A national salt industry
assessment, completed in early 1995 showed that one company in Ulaan Baatar handled the
major part of the salt used domestically, including imported salt, and was keen to cooperate.
Many small-scale producers located near the natural salt deposits were also willing, but they
stated a need for assistance for equipment, technical guidance and the fortificant, which the
National UNICEF Committee of Japan was prepared to finance, on request.
26. Concerned about the serious consequences of IDD in Mongolia, especially the loss of
learning capacity and future productivity in each next generation, the Minister of Health in early
1995 decided to press for a resolution and an ICCIDD expert was recruited to help develop a
national program, to be launched at a National Advocacy Event. A preparatory meeting in spring
1995 with 30 Mongolian scientists from various disciplines revealed differing opinions about the
need to iodize the salt for animals and for the population section presumed to be “not at risk”,
but failed to produce outright opposition to IDD elimination. Thus, the major technical elements
to be planned related to resource mobilization, training gaps, equipment sourcing and
installment, salt packaging, laboratory services for monitoring, and the creation, enactment and
enforcement of a mandatory law. The Minister of Trade and Industry was approached with
success for his political support in compelling the food industry to use only iodized salt in food
preservation, and for developing national regulation that all imported food should be fortified,
including imported salt. The Prime Minister’s Office made its National Development Secretariat
9
responsible to coordinate the proposed national program with the foreign aid on offer. And while
Mongolians were being trained in policy management, epidemiology and scientific monitoring
methods in China and Thailand, a draft national plan was being readied for discussion and
agreement at the National Advocacy Meeting.
27. Announced by the President who personally attended for two hours to listen to the
commitments of 5 Cabinet ministers, the National Advocacy Event on IDD Elimination was
staged on 3 November 1995 and laid out a national policy for the universal iodization of salt,
whether domestically produced or imported. The Declaration of the Event listed appropriate
roles and responsibilities of the public, private and civic sectors and Ministries were specified
with the respective program areas they should take charge of. Following the National Event, the
Government of Mongolia adopted the 1st National Plan of Action for IDD Control on 13 January
1996 and nominated a National Council for IDD Control under chairmanship of the Deputy
Chairman of the National Development Board who also is Vice-Minister of Health. The Council
is obligated to publicly report on progress once every year.
28. In 1995-96 as gesture to initiate action under the agreed plan, UNICEF donated 1,700
kg potassium iodate for domestic salt producers and from 1994 to 1998 it provided 16 iodization
machines to the domestic salt enterprises. An election in July 1996 changed the parties in
power from communist to liberal, and the new Government pledged its continued support for the
IDD program. The Japanese government added Japan International Cooperation Agency (JICA)
support after a positive fact-finding mission in September 1996 and JICA donated another 1,640
kg potassium iodate and 20 batch-iodization spray machines to the salt enterprises. By spring
1997, 51 out of the 57 retailer shops visited at random in Ulaan Baatar were found selling
iodized salt at a sales price of US$0.32-0.50 per kg as compared to US$0.13-0.35 for common,
non-iodized salt. The same study also reported that 73% of the salt used for consumption in 264
households from 6 central districts in Ulaan Baatar was iodized. In spite of the sizable price
difference between iodized and non-iodized salt, the Ministry of Health reported in 1998 that
67.7% of the households in Mongolia used adequately iodized salt. The official end-of-decade
report noted 45% as the consumption rate for adequately iodized salt, however. The domestic
salt production was estimated to constitute more than 40% of the total salt consumption in
Mongolia at that time.
2. Central Asia
29. Notwithstanding the clear directions from the Workshop in Ashgabad, the economic
difficulties associated with the transition, the privatization of salt and other food enterprises and
the absence of regulatory acts and economic levers of incentives for the productive sector were
increasingly leading to reduced supplies of iodized salt in the Central Asian Republics. The
share of non-iodized salt of domestic and foreign origins inclined, which then became reflected
in even more reports of signs and symptoms of iodine deficiency in the population. In
Kazakhstan, less than 25% of the local salt production was reported as iodized by 1993. The
goiter prevalence among schoolchildren in Kentau town located in South Kazakhstan Oblast
reached 26 percent (1,025 persons examined) by 1997 while among adults, a goiter rate as
high as 50-60 percent was cited. According to reports from obstetrical facilities in Almaty,
hypothyroidism was diagnosed in 7.2 percent of newborns in 1996, i.e. 150-300 times higher
than records of iodine-sufficient countries. The need for a national policy on nutrition, including
IDD elimination, was raised in Kazakhstan for the first time in 1996 at an International
Conference held in Almaty with support of United Nations Development Programme, UNICEF
and USAID. Follow-up action to start (re)building the national capacity to address iodine
deficiency through salt iodization took place with assistance of the Central Asia Area UNICEF
10
Office in 1997. Financial and technical assistance were provided to the salt enterprises AralTuz
and PavlodarSol by donating and installing spray iodization units and the free supply of 6,500kg
potassium iodate over three years. In 1999, in conjunction with the 1st Demographic Health
Survey, the Kazakh Institute of Nutrition in Almaty (later renamed to Academy) carried out a
large-scale population-representative survey, focusing on urinary iodine excretion among
women of reproductive age as iodine deficiency index. The median urinary iodine concentration
(UI) was 95µg/L and 29% of the households in Kazakhstan at that time were found to be using
adequately iodized salt (15mg/kg and above).
30. In Kyrgyz Republic, Government accounts of 1993 reported that only 17% of the salt
samples taken from the consumer markets met the desired level of 25-35 mg iodine per kg salt.
Surveys in 1991 had shown goiter prevalence among adults of 25-28% in Bishkek, Chui and
Issykkul Oblasts, and thyroid diseases reported by the health facilities were rapidly moving up
from 1992 onward, most likely due to increased goiter diagnoses. A rapid assessment in
preparation of the Ashgabad meeting measured thyroid volume and urinary iodine among 441
children aged 7-11 from 14 schools selected in the 4 most populated Oblasts Bishkek,
Jalalabad, Osh and Naryn, finding 39% goiter and 30µg/L urinary iodine; both indicative of
moderate to severe IDD. In addition, the thyrotropin (TSH) level in cord blood samples collected
from 190 newborns in the main maternities of Bishkek, Osh and Naryn was elevated in 60% of
cases, thus confirming that IDD was a severe public health problem.
31. In September 1994, the Prime Minister signed a “Decree on Elimination of IDD in the
population of Kyrgyz Republic”, stipulating that all food-grade salt for human and animal
consumption should be iodized according to the inter-state industry standard (GOST) that had
previously been in force in the USSR. The salt supplies in Kyrgyz Republic at that time
originated mainly from Kazakhstan (the Aral Tuz Company) and local deposits, each having an
estimated 40% share of the overall consumption, while the remainder consisted of imports from
Turkmenistan and Ukraine. As in the other post-Soviet Republics, the fortificant used was iodide
rather than the more stable iodate, while paper and carton packaging materials were in short
supply and salt was transported mostly by long railroad lines. Although a large salt deposit
exists in Toktogul, 250km from Bishkek, the Kyrgyz salt market stayed dependent on imported
salt, which due to the price competition shifted increasingly to the Kazakh sources. By 2000,
three-quarter of the salt consumed in the country was imported from Kazakhstan. Partly to
promote local iodization, three small salt packaging operations had been started which sourced
their raw salt from AralTuz and a natural deposit in Zhambyl Oblast, both in Kazakhstan, and
during 1997-98, UNICEF assisted by donating 3 continuous spray iodization units and 200kg
potassium iodate to each company. During the second half of the 1990s, SES inspections
routinely disqualified up to 50% of the salt samples found in local markets and occasionally,
batches of illegal were removed from circulation. The Demographic Health Survey of 1997
found that only 27.2% of the salt used in the households was adequately iodized. Even with the
clear evidence of a severe IDD problem in hand, and the official commitments made at the
World Summit for Children and the Ashgabat Workshop, however, the Government intent to
develop a national program, including legislation and enforcement of salt iodization, came to
fruition only after the decade had ended.
32. Tajikistan, the poorest among the former Soviet States, went through repeated periods
of instability and civil conflict during much of the 1990s. Historically, the country was known for
the severe IDD prevalence in its population. For example, during the 1930s, 5% of the people in
the Vanch Valley of Pamir (now Gorno-Badakhstan) were reported to be cretins. Up into the
1970s, the IDD extent was reported to have been reduced to mild but as in other Republics,
also in Tajikistan less attention was paid to IDD during the 1980s. The persistent economic
11
crises and frequent unrests for two decades precluded any systematic scientific documentation
of the iodine situation in the population. A rapid assessment in April 1994, however, showed that
goiter in school-aged children was as high as 42% in Dushanbe and 86% in Tursun-Zade, an
area selected by local endocrinologists for its historically high IDD burden. The UI among these
groups was 34 and 12µg/L, respectively, thus confirming that the iodine consumption had
become severely deficient again.
33. Under Soviet policy, a large-scale industrialization scheme had been started in Tajikistan
at Yavan, 60km east of Dushanbe, in 1984, which included a steam power electricity plant, a
chemical factory (for chlorine, caustic soda and soda ash) and a salt vacuum-evaporation plant
of up to 180,000MT capacity Namaki Yovon). Construction was suspended in 1994, however,
with the salt plant only 60% completed. Thus, the salt supply for the 5.5million population during
the first part of the 1990s was covered by two solar evaporation plants, each under local
administration, namely in Voce, Kathlon Oblast in the South (Khodja Mumin) and another similar
plant in Asht, Soghd Oblast in the North (Koni Namak), each having 30-40,000MT capacity,
sufficient to satisfy the domestic salt consumption needs.
34. In May 1997, upon improvement of the security situation and in spite of a severely
constrained economy, the Government of Tajikistan issued an approval Ordinance for a national
program of IDD control giving priority to salt iodization, along with goiter case detection,
registration and treatment. The GOST standard was adopted to give guidance to the industry
and for inspections of salt in the markets by SES. At that time, health facilities reported a thyroid
disease case load of near 6,000 per 100,000 people likely due to high goiter morbidity. The Koni
Namak and Khodja Mumin salt plants were both equipped by UNICEF with a wet-spray
iodization unit and a salt iodine monitoring laboratory in 1998, while Tajik engineers managed to
get the Yavan plant starting production, albeit at a low production level compared to the initial
plans. To further stimulate iodization, UNICEF donated 6,000kg potassium iodate among the 3
salt plants, leading to reported iodized salt supplies as high as 80% of the total salt supplies by
2000. Yet, the MICS of 2000 reported that only 20.2% of the salt tested in households was
adequately iodized.
35. Until 1991, all the salt for human consumption in Uzbekistan was imported from Ukraine
and Kazakhstan, reportedly duly iodized according to regulations. Along with the declining inter-
state trade after Independence due to the shortage of hard currency, the Uzbek Government
tried to stimulate local salt production and by 1993, it was reported that about one-third of the
edible salt consumed in the country was produced locally. Iodization of the salt was of
secondary concern at that time. During the 1990s, salt production and mining plants were put in
operation in Surkhandaria, Karakalpakstan and Navoi Oblasts, with part of the production being
shipped for processing in Tashkent. Between 1997 and 1999, UNICEF donated 8 spray
iodization units and 16,400kg potassium iodate to various producers and processors in an effort
to stimulate an increase in iodized salt supplies to the population. UNICEF also offered support
for the development of a national IDD program, but high-level interest to address the IDD
situation did not become apparent prior to the turn of the Century, even though Government
officials had participated in the ECO Workshop in Ashgabad in 1994. Survey data of the Institute
of Endocrinology in Tashkent had shown that iodine deficiency prevailed at 15% of the school-
aged population prior to the 1990s. A mean urinary iodine excretion of 35µg/24h was reported
for children in Tashkent – much below the normal minimum level of 100. A UNICEF report
mentions that the Institute of Endocrinology conducted another national survey in 1997-98
which indicated that goiter had increased to more than 40%. The MICS of 2000 was the first
nationally-representative survey of iodized salt use in Uzbekistan. Only 19.2% of the
households were found using adequately iodized salt.
12
Figure 2: Mother with a Cretin Child, Institute of Endocrinology, Tashkent, Uzbekistan,
Mid 1990s
C. Some Noteworthy Experiences and Lessons Learned
36. By the end of the 1990s, the need for USI had been broadly accepted in the JFPR
countries in Central Asia and Mongolia. No objection was voiced against salt as the key vehicle
to convey additional iodine consumption of the population. Unlike in other parts of the world,
neither in Central Asia or in Mongolia was there discussion whether the customary salt intake is
healthy. Also, in contrast to many countries where the proposition of the USI strategy was still
relatively new, there was acceptance in the countries of Central Asia that the serious magnitude
of the IDD problem made a universal strategy necessary, meaning that it applied to all the salt
that ends up in the human diet, and serving the entire population. Little -if any- resistance to USI
was heard from the scientist or from the public, private and civic sectors. Without doubt, the
historical experience of the Soviet Ordinance must have played a role in the broad and ready
political acceptance of the USI strategy idea. Importantly also, by the incessant advocacy by the
lead Academician of the Kazakh Academy of Nutrition (KAN)—who is a highly regarded
previous Minister of Health-, USI became perceived as the dietary solution for a nutrition
problem, rather than a selective, prescribed remedy for disease. In contrast, objections among
influential scientists in Mongolia against iodizing salt and its extension to rich, well-to-do
consumers required a dedicated conference to discuss their views and challenge their evidence
basis, which led to a delay in getting the national policy underway.
37. Moreover, although the historical experience in the JFPR countries was based on
potassium iodide as the fortificant for salt, no objections were voiced by salt producers and/or
their customers upon the free supply by UNICEF (and JICA) of potassium iodate. Convincing
evidence was made readily available from studies in Central America of the superior
effectiveness of potassium iodate over the iodine that was previously habitual. In the JFPR
countries, no questions or concerns were heard whether potassium iodate is safe, contrary to
other countries at that time. As to the willingness and acceptance among consumers, the
Russian language has interchangeable words for “fortification” and “enrichment”. Therefore, the
notion and need of adding a nutrient to a common food is easier communicated in a positive
sense in Russian, which may have been a reason why misunderstanding and resistance among
consumers was less likely to occur.
38. Up to the mid 1990s, when UNICEF established an Area Office in Almaty, Kazakhstan,
and Country Offices in each of the Central Asian Republics, the realization was beginning to
dawn that the USI goal could not be pursued with success only through a Government-led
13
approach together with scientist-organized meetings. An archetype change in approach
followed, based on an increasing recognition that neither the scientists, nor the agencies or the
Governments owned, produced, or sold salt. The “industry of salt” was the domain of the salt
producers and their allies in trade and retail. Consequently, part of the challenge for the public
officials, the scientists and the agencies was the need to come to terms with the notion that an
analysis of the salt production and market supply system, and of the salt uses in households
and food industry, were as important for program design and direction as were a population
iodine nutrition survey.
39. By the end of 1999 in Central Asia, UNICEF had donated a sizable number of iodization
equipment and a significant amount of potassium iodate, sufficient in theory to enable the
iodization of a major part of the national edible salt supplies. The disappointingly low outcomes
in the supplies and use of iodized salt in the households of Central Asia indicated, however, that
more was needed than just the mere provision of inputs to the industry. The centrally
orchestrated oversight and directives that had been characteristic of the goiter control efforts
during the 1950s-60s had completely disappeared. And although the presence of essential
inputs is necessary, they were obviously not sufficient to persuade the salt producers to ensure
exclusive supply of good quality iodized salt. Understandably, the salt productive sector did not
see the resolution of a health issue as its core value. The purchase orders from their customers
didn’t specify that the salt should be iodized, obligatory certification by a State Standards
Agency had not been firmly introduced, and the threat of penalties associated with market
inspections was low. Clearly, USI could not be reached, and IDD could not be overcome,
through stimulation of only a single sector.
40. Although in Mongolia the lessons learnt were not dissimilar from those in Central Asia,
the path followed and experiences obtained were different. Notably, a National Advocacy Event
had launched the USI policy, followed by a 1st National Plan of Action for IDD Control that
allocated roles and actions to various sectors and identified the efforts to be contributed by the
respective Ministries. This approach had the potential that the high political levels in each
named organization would be concerned with making sure that progress would happen
afterward. After early 1996, however, no more landmark achievements followed. The legislation
and regulation necessary for safeguarding the agreed-upon USI strategy did not come through
and the overall focus remained on the attempt to develop natural salt resources. Compared to
the amount of salt consumed in the population, noting that much of the salt consumed was
derived from imports, the number of iodization machines and amount of potassium iodate
donated in Mongolia were excessive of the true need and, moreover, the quality standards
maintained from before 1990 were unrealistic. Notably also, visits by international consultants
during the final years of the 1990s did not produce unity of recommendations. Thus,
notwithstanding the huge assistance that followed the launch of a national program in 1996,
only little more than half of the households in Mongolia used iodized salt by the turn of the
century.
41. In summary, the collective experience in JFPR countries by the end of the 1990s was
that a fundamentally different approach was needed. The way forward should be sought in the
cohesive blending of the abilities in public, private and civic sectors to address the issues of
dietary iodine deficiency; the overall effort should be based on mutually supportive actions by
concerned people of these origins who could marshal on priority the range of knowledge, talents
and resources required; and importantly, the contributions by each sector and specialty in the
elimination program had to become guided and overseen by a national “partnership”
arrangement of all the key sectors involved.
14
D. End-of-1990s-Decade Status of Salt Iodization
42. In anticipation of an end-decade assessment of the progress toward the World Summit
of Children’s goal of virtual IDD elimination, WHO published in 1999 a comprehensive review of
the global IDD status based on the information sources available such as the ICCIDD country
reviews, CIDDS database and reports of WHO, UNICEF and the IDD Newsletter. Azerbaijan,
Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan were listed among the 130
countries of the 191 WHO member States known to be affected by IDD. The review reported
that iodized salt standards had been adopted in Kyrgyzstan, Tajikistan and Mongolia, and that a
national coordinating body and a national action plan were in evidence in Mongolia.
43. The end-decade progress made in reaching USI was published as part of the events at
the Salt2000 Symposium in The Hague in May 2000. Reports from large-scale surveys
documented by UNICEF indicated that more than 70% of the households in the world were
using iodized salt by the turn of the century, compared with less than 20% in 1990. In 31
developing nations, iodized salt was used in more than 90% of households, and in an additional
36 nations, more than half of the population was using iodized salt. By UNICEF region (Figure
3), the progress in USI was seen to vary from close to 90% in Latin America, 50-70% in most
other regions, and down to 22% of households in Eastern Europe, the Commonwealth of
Independent States, and the Baltic States. The overall regional progress, therefore, did not differ
significantly from that in the JFPR countries of Central Asia.
Figure 3: Global Status of Salt Iodization by UNICEF Region, Year 2000
Household Salt Iodized
Percent 0 10 20 30 40 50 60 70 80 90 100
E/S Africa
W/C Africa
M East/N Africa
S Asia
E Asia/Pacific
C/S America
E Europe/CIS/B
Other unknown
44. From using a country’s population size and crude birth rate, an approximation of the
number of newborns per year for a country can be obtained, and when taking into account the
salt iodization user rates in the households, the number of newborns born in households
consuming iodized salt can be calculated. Figure 4 shows the approximate numbers of
“protected” and “unprotected” newborns by UNICEF region at the turn of the Century. By end
1999, almost 85 million newborns out of approximately 130 million worldwide were protected
against the brain damage from iodine deficiency because of the use of iodized salt in their
households when their mothers were pregnant. For the UNICEF region of Eastern Europe, the
Commonwealth of Independent States, and the Baltic States, the approximations were that of
the 5.7 million newborns entering the region during the year 2000, 1.3 million were born in the
15
households where expectant mothers had used iodized salt, thus boosting the intelligence of
their newborns.
Figure 4: Brain Protection from the Use of Iodized Salt in Households by UNICEF Region,
Year 2000
Brain protection among Newborns
Million/yr 0 5 10 15 20 25
E/S Africa
W/C Africa
M East/N Africa
S Asia
E Asia/Pacific
C/S America
E Europe/CIS/B
Other unknown protected
unprotected
45. And for the countries of Central Asia and Mongolia, based on the best salt iodization
data available, it was estimated (Table 1) that less than one quarter of the newborns in the
JFPR countries at that time were delivered by mothers from households consuming iodized salt.
Table 1: Approximation of the Situation of Newborn Protection in the JFPR Countries of
Central Asia and Mongolia, Year 2000
Population in
millions Annual births in thousands a
Household
Protected Salt %iodized per 1,000 total number number
Total against ID Value Year population number protected unprotected
JFPR9005 countries, end 2000 situation
Azerbaijan 7.7 3.3 43 2000 15 115 49 65
Kazakhstan 14.9 4.3 29 1999 14 207 60 147
Kyrgyz Republic 4.9 1.3 27.2 1997 22 109 30 79
Mongolia 2.5 1.1 45 1998 20 51 23 28
Tajikistan 6.4 1.3 20.2 2000 21 134 27 107
Uzbekistan 24.8 4.7 19 2000 23 570 108 462
61.1 16.1 26 1,186 297 889
Data sources: ADB Salt Situation Assessments; UNICEF 75%
a
Population size and crude birth rates from UN Population Reference Bureau reports
46. Available information about goiter prevalence and urinary iodine excretion by country
was published in a 2004 WHO report entitled “Iodine Status Worldwide”. Table 2 summarizes
the programmatic status in the JFPR countries, embellished by country with more details
gleaned from the various information sources used in the present historical perspective. These
data may serve as a summary benchmark for reference at the completion of the JFPR project.
16
Table 2: Summary of National Iodine and IDD Elimination Policy and Program Status in the JFPR Countries in 2000
Indicators Kazakhstan Kyrgyz Republic Mongolia Tajikistan Uzbekistan
Population (million) 14.9 4.9 2.5 6.4 24.8
GDP (US$/capita) 5,000 2,700 1,780 1,140 2,400
Iodine Deficiency Moderate to severe Moderate to severe Mild to moderate ID, Moderate to severe Moderate to severe
Extent ID, DHS 1999: ID, small studies national survey ID. Cretinism in ID, non-
Most recent survey, goiter Median UI 95µg/L school-aged children school-aged children GBAO known representative large-
prevalence among WCBA. 1994: 39% goiter, 1993: 29% goiter. All historically. Small scale surveys in
(US/palpation), urinary Cretinism known Median UI 30µg/L; but 2 Aimags studies school-aged 1997 show goiter
iodine, TSH, cretinism historically TSH elevated in 60% affected, ID most children 1994: goiter increase school-
of newborns in major severe in C and W 42- 86% in aged children to
maternities Mongolia and Ulaan Dushanbe and >40%. Children in
Baatar Tursun-Zade Tashkent UI
35µg/24h
Salt Industry Salt locally More than 75% salt Majority of salt Three major Major salt deposits
Number of salt producers, produced, mainly by imported from imported from producers in N, C developed to
amount of edible salt AralTuz (80% of Kazakhstan (AralTuz Russia or China. and S Tajikistan. production under
produced, imported and national supply) and and Zhambyl). 3 Local consumption Exports to Kyrgyz Government
exported, packaging PavlodarSol. Imports local processors, from many natural Rep, Afghanistan administration,
in W and NE poor packaging, no deposits. Simple and Uzbekistan. packagers in
Kazakhstan from labeling methods, poor Poor quality salt, Tashkent. Poor
Russia quality salt poor packaging packaging, no
labeling
Salt Iodization Iodization with KIO3 Interstate GOST Voluntary iodization Interstate GOST No mandatory level
% adequately iodized at 23±11mg/kg has mandates level 30±5 mg/kg. mandates stated by
household salt, level been introduced at 23±11mg/kg. KIO3 Border control not 23±11mg/kg. KIO3 Government. Local
mandated, iodine both AralTuz and has been introduced. functional. Use of has been introduced. producers and
compound, cost of Pavlodar. Industry Local processors are salt from natural Industry QA and processors equipped
iodized salt QA and food control equipped. QA, food deposits highest in food control but industry QA and
practices not yet control and W Mongolia. Survey practices not yet food control
settled. DHS 1999: enforcement in 1998: 78% HH settled. Iodized salt practices are
29% HH adequately practices are weak. adequately IS. supplies reportedly unclear. KIO3 has
IS DHS 1997: 27% HH Iodized salt about up to 80% of total been introduced.
adequately IS twice as expensive production. MICS MICS 2000: 19% HH
as non-iodized 2000: 20% HH adequately IS
adequately IS
17
Legislation/Regulation Legislation pending. 1994 Decree of PM Legislation pending Legislation pending Government
Principle act, subsidiary In practice, interstate mandates iodization commitment weak.
norms and regulations GOST still being of all edible salt. No effort to prepare
followed Parliamentary law for legislation yet
being prepared
National Coalition No effort yet made to No effort yet made to National Council for No effort yet made to No Government
Establishment, promote a Coalition promote a Coalition IDD Control, multi- promote a Coalition experience of
composition, meeting sector, chaired by partnership building.
frequency Deputy MOH No effort yet made to
promote a Coalition
National Program National Program National Program National Program National Program National program not
Acceptance, major being prepared, not yet being launched in 1996, not yet being yet being considered
components, financing, main strategy USI considered main strategy USI. considered
budget support but also Local budget with
supplements being UNICEF and JICA
considered support
Progress Monitoring Dependence on No national surveys, National Survey Dependence on Institute of
Arrangement, laboratory large national but donor-driven completed in 1999. large national Endocrinology plays
capacity, reporting surveys. Kazakh small scale studies Results pending surveys. central role but relies
Academy of Nutrition in project areas Endocrinology on small-scale
well qualified Dispensary is studies
qualified
Human Resources Government officials Need for training in Strong role by Public Government officials Government officials
Institutions, training and industry staff industry QA, lab Health Institute. and industry staff and industry staff
needs, international generally well capacity weak. Food Links with Japanese weak and need weak and need
linkages qualified inspection training and Chinese training training
needed scientists
Donor Involvement UNICEF UNICEF UNICEF, JICA UNICEF, Aga Khan UNICEF
C = central, DHS = Demographic Health Survey, GBAO = Gorno-Badakhshan Autonomous Oblast, GOST = common food and (other product) standard, HH =
household, ID = iodine deficiency, IDD = iodine deficiency disorder, IS = iodized salt, JICA = Japan International Cooperation Agency, KIO3 = potassium iodate.
MICS = Multiple Indicator Cluster Survey , MOH = Ministry of Health, N = north, NE = north east, PM = Prime Minister, QA = quality assurance, S = south, , TSH =
thyrotropin, UI = urinary iodine, , USI = universal salt iodization, UNICEF = United Nations Children's Fund, W = west, WCBA = women of child-bearing age
.
18
E. Preparations for the Almaty Forum 2001
47. The Almaty Forum, held 8-12 October 2001 in Almaty, Kazakhstan, represented the
culmination of a process set in motion when in late 2000 the JFPR agreed to a $6 million grant
proposal to assist countries in Central Asia and Mongolia with piloting national efforts to
increase the supply of fortified salt and flour to the population, especially poor women and
children. Early on, ADB sought close collaboration with UNICEF and it solicited technical
expertise through the KAN, a reputed science resource in the region.
48. During the spring of 2001, ADB Senior Project Officer Dr Joseph M. Hunt visited the
capitals of the countries invited to the project to negotiate consents by the Ministries of Finance,
the official ADB counterparts, and the Ministries of Health for assuming the Executive Agency
(EA) role and hosting the units for national plan implementation. The outcome of these trips in
each country was a “Note of Discussion” in which the Government counterparts committed to
apply fiscal and trade reforms for the duration of the project and develop a Country Investment
Plan (CIP) for submission to ADB according to an initial outline accompanying the grant
proposal. The trip contributed significantly to stimulating the formation of multidisciplinary teams,
tasked to develop the CIP’s and present them at a collective Forum planned for the second part
of 2001.
49. In May 2001, the Presidents of Azerbaijan, Kazakhstan, Kyrgyz Republic, Tajikistan and
Uzbekistan were among the Heads of State who supported the acceptance of an agreement on
the prevention of iodine deficiency in the Commonwealth of Independent States, signed by the
Prime Ministers in Minsk, mentioning: “… the necessity of work to be performed within a
framework of mutually agreed and mutually accepted systems of national control of the quality
and safety of foods during production, storage, transportation and sales”. The agreement
specified that: “Parties shall pursue a coordinated iodine deficiency prevention policy in the
populations of CIS countries; and they shall work toward harmonization and unanimity of
requirements as specified by national State Sanitary-Epidemiologic Supervision authorities for
the development and adoption of unified methods of control over the composition of foods”. In
Central Asia, the Minsk agreement offered an important starting point for agreeing to a common
framework for the legislation and execution of the salt iodization policies.
50. Realizing the unique opportunity afforded by the JFPR grant for the acceleration of
efforts to address micronutrient deficiencies, the Representative of UNICEF in Central Asia in
close coordination with the ADB senior officer invited a UNICEF consultant in June 2001 to
assist with conducting a Salt Situation Analysis (SSA) in each country targeted by the JFPR
grant, except Mongolia where another UNICEF consultant had made a complete inventory of
the Mongolian salt industries in January 2001. The purpose of the SSAs was to contribute in
clarifying the key obstacles and barriers faced by the salt industry in each country and thereby
obtaining guidance for the support to be provided for accelerating the progress toward USI.
51. The methods and instruments for the SSAs were developed together with a scientist of
KAN, and the two experts held a training meeting for two-person teams of Azerbaijan,
Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan to introduce the methods and
instruments, orient the teams on conducting the SSAs, and discuss the reporting of findings.
During July 2001, the KAN scientist provided coordination and backstopping to the SSA teams
working in each country. A summary report was forwarded to ADB by the end of August 2001.
The teams had identified and made visits to a total of 20 salt industries, in addition to responses
on a questionnaire of the basic information on legislation and regulatory practices in the public
service sector.
19
52. The SSA report (Appendix 1) identified significant, although variable, shortfalls in the
reported amounts of salt supplied in each country. In many of the industries, the equipment and
machines for salt harvesting and processing were seriously outdated, under-maintained and in
dire need of replacement. The fortificant in use for the salt iodization step originated from
donations by UNICEF and Aga Khan Foundation (in Tajikistan), except for Turkmenistan where
potassium iodate was used, manufactured by the Cheleken factory. Only in a few instances,
procurement of the fortificant was undertaken by salt industries themselves, directly or indirectly
from Russian sources. Although packaging had been initiated in small 0.5 and 1kg polyethylene
bags for consumer use in some enterprises, most of the salt supplies were being packed in
paper/carton or polypropylene woven bags. Local regulations required that the name of the
producer, contact information, type of salt, expiry date and storage instructions was imprinted on
all packages.
53. The SSAs also reported responses that all the industries had switched to using
potassium iodate and that the inter-state GOST standard was being followed for the salt iodine
level if iodization took place. Reportedly, all factories practiced some routine method of internal
quality assurance, while the SES authorities of Azerbaijan, Kazakhstan, Kyrgyz Republic,
Tajikistan and Turkmenistan reported to conduct regular external control tests, sometimes with
associated penalties or forced removal of an affected batch of salt from the market. The market
price of iodized salt was considered affordable for consumers, with an apparently non-significant
consumer price difference for iodized and non-iodized salt. Finally, the SSA report mentioned
that large natural salt reserves were present in each country. Importantly, the SSA reported a
great variety in the nature, mechanism and authority of the existent regulatory requirements
among countries. The SES had been formally authorized in all countries to conduct salt iodine
quality inspections at production, importation and retail. The enterprises were reported to be
operating under licenses controlled by local Oblast authorities who collect sales tax on volume
throughput. All enterprises mentioned that they must pay tax on goods or products bought
(packaging) or imported (equipment, iodate).
54. The SSA results provided input in initial estimates of needed support for iodization and
packaging technology, as well as for some of the desired capacity building in regulatory and
monitoring systems for each country invited in the project. The ADB officer used the SSA report
to sharpen the text of the draft guideline for development by national counterparts of the CIP
(Appendix 2). The preparations and initial estimates of the support for flour fortification followed
a different approach because this part of the project also included the design and formulation of
a common premix and common procedures for quality assurance and control in the milling
industry, inspection authorities and government departments. To be able to demonstrate quick
progress, the overall orientation of the strategy for flour fortification was to prioritize the
fortification assistance to a selection of the larger mills in each country.
55. Meanwhile, the preparations for the ADB/JFPR project launch proceeded on parallel
tracks:
(i) ADB issued Letters of Agreement to each Ministry of Finance and disbursed a first slice
of the grant for preparatory work on the CIP and to finance the participation by multi-
sector country teams in a joint Roundtable planned in Almaty, Kazakhstan. The Ministry
of Health was invited as Executing Agency, and arrangements were to be made for
administrative and financial management by establishing a Country Project Office (CPO)
in each MOH. Also, in July 2001, ADB established a regional coordination and
20
administrative office (RCAO), which helped facilitating the ongoing work of the salt
situation analyses and the flour fortification assessments,
(ii) To facilitate decisions on investments in salt iodization in each country, and in
coordination with the conduct of a SSA, UNICEF project officers in each of the countries
started to provide assistance in CIP development, and coordinate the exchanges of
information among partners and the country teams involved in drafting the CIP,
(iii) ADB contracted reputed specialist consultants (Nevin Scrimshaw – Program policy,
Gary Gleason - Communications and Peter Ranum – Flour fortification) and entered into
an agreement with the KAN for the development of planned project components and
specialized technical assistance (for example, a standardized iron-based wheat flour
fortificant formula). In collaboration with UNICEF consultants Gregory Gerasimov and
Frits van der Haar, an agenda and work program for the Almaty Forum was being
drafted and sent to the capitals of countries for their inputs, and
(iv) The first draft inputs for the CIPs started coming in during August 2001. Coordinated
through ADB, the above-named ADB consultants prepared detailed comments and
these were shared with the country teams to assist in their preparation of final draft CIPs
as input for the Almaty Forum. In the initial drafts, generally little detail had yet been
included of implementation arrangements (including the local organizations), while the
drafts were generally short of detailed justifications for the selection of proposed
activities and resources, as well as of an explanation of how the resources were
expected to lead to the stated project outcomes.
56. The initial invitation missions by ADB also included a visit for discussions with potential
partners in Turkmenistan. The Turkmenistan Government did not consider the project
sufficiently valuable, however, from their viewpoint that USI and flour fortification were already
being pursued and that the poverty in the population was not sufficiently high to warrant an
additional project 3 .
3
In conjunction with the Ashgabad meeting in 1994, the President of Turkmenistan had decreed that all salt and all
flour provided to the population should be fortified. Between 1996 and 1999, UNICEF donated 3 iodization
machines, 12 micro-feeders, 6MT flour fortification premix and 3,500 sets of rapid salt test kits in Turkmenistan.
21
III. THE ALMATY FORUM 2001
57. Uniquely for that time in Central Asia, the Almaty Forum 2001 brought together national
multi-sector delegations composed of leaders of public, private, scientific and civic origins to
discuss the policy and program needs, and define the national strategies, timelines and targets
to reduce micronutrient deficiencies in their populations by food fortification, and in the particular
case of iodine deficiency, USI. The Asian Development Bank, fiduciary of the JFPR grant, had
the main initiative in this Forum and worked in close collaboration with UNICEF, KAN and expert
consultants in conducting the Forum.
58. The Almaty Forum 2001 was held from 8 to 12 October 2001 with 2 interrelated program
elements:
(i) A Conference, consisting of a series of scientific presentations to address contentious
issues and seek policy agreements on regional and national approaches, while sharing
previous experiences from national fortification efforts in other countries of the world,
and
(ii) A Roundtable, consisting of a series of discussions, plus drafting and redrafting sessions
to improve upon the details of the CIP of each country delegation.
59. The delegations of the countries were headed by the Minister of Health or alternate, and
consisted further of some combination of parliamentarians, senior staff of the President’s
Offices, high-level executive staff from the salt productive and flour milling industries, lead
national scientists, key non-government organizations and chief executives of SES. In several
staged working groups arranged by country, the consultants provided inputs according to their
specialty, and they assisted further in improving the project consistency of CIPs. The
Conference culminated in a Consensus Statement, named the Almaty Declaration (Appendix 3).
60. The Almaty Forum was concluded with a signing ceremony between the Heads of the
Delegations (Ministers or Deputy Ministers of Health) of Kazakhstan, Mongolia and Uzbekistan,
and the ADB Director of the Economic and Social Service Division, Mr. William M. Fraser. The
Health Ministers of Kyrgyz Republic and Tajikistan had been recalled to their capitals for
reasons associated with the attack by American military forces in Afghanistan. However, the
CIPs of these countries were ready for signing and the ADB country representatives reached
agreements with the Health Ministers in the capital cities during the following weeks. Azerbaijan
had submitted a draft CIP prior to the Forum and was invited as “observer” only because the
official membership relation with ADB was being re-negotiated at that time. ADB indicated a
desire to also sign the agreement with Azerbaijan.
A. Short Outline of the JFPR9005 Project
61. The JFPR9005 Project, thus officially launched at the Almaty Forum 2001, aimed to
improve the nutrition status and physical and mental capacity of the poor by piloting an umbrella
regional program for delivering micronutrient-fortified salt and wheat flour to the populations of
participating countries. In each country, the project set out to:
(i) Focus support on the poor currently afflicted or at risk,
(ii) Experiment with and pilot-test interrelated capacity-building processes to establish
national and regional networks of marketing, distribution and rules of trade, and
22
(iii) Demonstrate the efficacy of a collaborative approach to solve a common nutrition
problem.
The project components specifically included
(i) Fortification of salt and flour. In selected sites in poor areas, governments were to work
with flour millers, bakers, and salt producers to upgrade processing and marketing
technology (private-sector financed) to use micronutrient-enriched salt and wheat flour.
The Project set out to finance a one-year supply of fortificants (potassium iodate and an
iron-based premix) for salt and flour consumed by the poor. Both private and state-
owned companies were eligible for assistance on the provision that they intended to
continue fortifying products afterwards,
(ii) Support for regulatory authorities. Food inspection bodies were to develop food-test
instruments and food quality control methods to monitor the enriched food program for
mothers and children, and
(iii) Communications to strengthen acceptance by the poor. This activity was to be managed
by NGOs to promote public awareness and acceptance of micronutrient–enriched salt
and wheat flour, targeting poor consumers.
62. The total cost of the Project was assessed at US$6.24million, $6.0million of which was
offered on a grant basis from the JFPR. National and local government budgets, NGOs, and the
private sector financed the remaining $240,000, largely by in-kind contributions. It was
envisaged that assistance in each country would also be provided by UNICEF, especially for
public education and surveillance, in its role as the lead UN development partner involved in
USI.
63. In each country, the Ministry of Health had accepted the role of EA for the project and it
proceeded to set up a CPO, where daily activities would be coordinated, and a Steering
Committee for project oversight. Due to the nature of the project, actions would be undertaken
in close collaboration with the private productive industries (salt manufacturers and flour millers,
with their customers) as well as with NGOs and community-based organizations.
1. RCAO
64. In ADB Headquarters in Manila, Philippines, a Senior Social Sector Specialist was
overall cognizant responsible officer. Management of the project was greatly facilitated by the
establishment of the RCAO in Almaty, Kazakhstan, on consultation with the EA’s of all
countries. In close coordination with ADB headquarters, RCAO was responsible for the
coordination of project activities among the participating countries as well as for centralized
procurement and guidance of major project inputs. In addition, RCAO had a major leadership
role in the design and conduct of regional forums, meetings and workshops; it assisted the EA’s,
CPOs and project stakeholders in executing core project activities in each country; and it issued
consolidated reports on project progress. In the course of project execution, RCAO conducted
several supervision visits and provided hands-on assistance and training in the specific
requirements of project administration and finance procedures.
B. Progress in implementing JFPR9005
65. The policy agreements reached at the Alma Ata Forum and detailed in the CIPs were
followed by preparations and ensuing work in each JFPR country. A country coordinator was
selected to head the CPO located in the Ministries of Health and responsible for funds
administration and reporting. A National Steering Committee, chaired by the Minister of Health
23
or her/his alternate, was nominated to oversee progress and ensure that all key national
partners were included in resource decisions and coordination of activities among the sectors.
Backed by regular discussions in the Steering Committees and continued support from the
RCAO, each CPO by end of February 2002 had submitted a final work plan, time line, budget
and Gantt chart to connect the work plan with delivery deadlines and budget estimates. At the
inception of JFPR9005 there was much variation among participant countries in the industries’
production infrastructure, population and their resident location, and in the salt trade networks
serving the food processing industries and the consumer markets. In addition, differing
capabilities existed in the Government monitoring and control services and, importantly, the
visions by the Ministry of Health’s leaders of the balance of approach to be taken in the project
differed. Added to this, there was limited prior experience in the countries with the execution of a
complex project among various sectors. Thus, it does not come as a surprise that the CIPs
showed significant variations in emphasis, proposed budget allocations, overall size of effort
and level of detail provided, especially in the implementation arrangements between the sectors
and organizations to be involved.
C. Stimulating USI during the JFPR9005 period
66. In September 2001, immediately following the Almaty Forum, ADB began a search for
two additional consultants, one for advising on salt iodization technology and another to support
the CPOs and Steering Committees in addressing the legal, regulatory and trade issues. The
Salt Institute, located in Virginia, USA, assisted in communications with Mr. Pan O. Varghese
who had extensive experience in salt production development in various developing countries of
the world. In late 2001, ADB entered into a consulting agreement with Mr. Varghese for the
conduct of assessment missions of the productive salt industry capacities and associated
information, which were accomplished during two trips during 2002: In February-March
(Kazakhstan, Kyrgyz Republic and Tajikistan) and in June-July (Uzbekistan and Mongolia). The
findings and observations from these expert missions significantly augmented upon the data of
the previous SSAs. A consolidated detailed summary of the information by country, believed to
be representative for 2001, is presented in Table 3. Table 4 uses this information to project the
gap in iodized salt supplies that needed to be addressed in each JFPR country to achieve at
least two-third of the total national salt supplies; the target agreed-upon as part of the
negotiations in each country in completing the CIPs.
Table 4: Salt industry in JFPR countries: Approximations for 2001
Salt
production Estimated Gap in
need, Approximate proportion Approximate iodized
Population estimated national salt locally domestic salt
size, mid at supply produced or consumption supplies to
2001 5kg/person estimate processed of iodized salt reach 66%
Country (million) (1,000MT) (1,000MT) (%) (1,000MT)* (1,000MT)
Azerbaijan 8.1 40.5 2.5 6% 22.6 4.1
Kazakhstan 16.1 80.5 20.0 149% 30.3 22.8
Kyrgyz Republic 5.0 24.9 7.0 28% 8.8 7.6
Mongolia 2.6 12.8 2.5 20% 8.7 0
Tajikistan 6.1 30.7 32.5 106% 8.1 12.2
Uzbekistan 26.3 126.3 30.0 24% 31.2 52.2
Total 63.1 315.6 194.0 62% 109.7 98.6
* Taking into account producer-provided data and the pre-JFPR estimates of the use of iodized salt in households. Note that
the estimates include imported salt.
24
67. The reports of the SSAs and consultant missions during 2001-2002 mentioned
repeatedly the high local salt production potential capacities. In contrast, the amount of actual
supply estimated on basis of producer self-reporting is likely a sizable under-estimate the true
domestic production, except for Kazakhstan and Tajikistan. In the cases of Azerbaijan, Kyrgyz
republic and Mongolia, the shortfall of the national supplies were known to be compensated by
imports from neighboring countries, but certainly in Uzbekistan the true amount of production
and/or processing of salt must have been sizably above the amount captured in the reports. The
available estimates at that time illustrated the great challenge ahead in raising the delivery of
iodized salt to the populations. The shortfall in iodized salt supply at the start of JFPR9005 was
in excess of 200,000MT/y. In view of the commitments in all the CIPs to increase the supply to
at least two-third of the national consumption estimate, the task ahead became to raise the
iodized salt supply by almost 100,000MT/y in total.
25
Table 3: Consolidated update of the Salt Situation Analyses carried out in Central Asia and Mongolia, 2001-2002
Population Reported Information of donor (UNICEF, etc)
size, mid Estimated salt Major salt industry edible salt assistance before 2001
2000* supply need production or supply production Iodization Potassium Other Other
Country (thousand) (MT/annum) (processing) sources (MT, 2000) technology iodate (kg) donations comments
Azerbaijan 7,734 38,670 Nakhchivan Salt Mine ± 1,000 yes, from Iran yes, no No internal
unknown QA
quantity performed
Dilek Ltd, Masazir lake 525 yes yes, no
unknown
quantity
Aimaz-93, Masazir lake 120 yes, Glotra yes, N/A
unknown
quantity
Crystal-Co, Masazir lake 10 unknown self- N/A
purchased
at
US$25/kg
Yashar Duz, Masazir lake 500 N/A N/A N/A Produces
also "Extra"
salt
General comment: According to information from Customs, 37,000MT salt imported during 2000, mainly from Ukraine and Turkey
Kazakhstan 14,865 74,325 Aral Tuz, Kyzl Orda Oblast 50,000 yes, Glotra 5,200kg lab titration Exports non-
(1999 and equipment iodized
2001) (technical)
salt
Pavlodar Sol, Pavlodar 10,000 yes, Glotra 1,300kg N/A
Oblast (1999 and
2001)
Taraz Tuz, Zhambyl Oblast 10-20,000 self- self- no (Joint all salt is
purchased, is purchased, Kazakh-US being
said to be is said to be project) exported to
underway underway KGZ
General comment: Kazakhstan is in theory self-sufficient, however, salt imports from Russia are sizable in W and E Kazakhstan Oblasts
Population Reported Information of donor (UNICEF, etc)
size mid Estimated salt Major salt industry production edible salt assistance before 2001
2000* supply need or supply (processing) production Iodization Potassium Other Other
Country (thousand) (MT/annum) sources (MT, 2000) technology iodate (kg) donations comments
26
Population Reported Information of donor (UNICEF, etc)
size, mid Estimated salt Major salt industry edible salt assistance before 2001
2000* supply need production or supply production Iodization Potassium Other Other
Country (thousand) (MT/annum) (processing) sources (MT, 2000) technology iodate (kg) donations comments
Kyrgyz 4,929 24,645 Khedef (processing), Bishkek 3,000 self- self- rapid test Import from
Republic manufactured purchased kits Aral Tuz
at
US$45/kg
Nur (processing), Bishkek 1,700 yes, Glotra 200kg rapid test Import from
(1999) kits Taraz Tuz
Mahabat (processing), Osh 600 yes, Glotra no rapid test Import from
kits Uzbekistan
Local small sources 1,000 no no N/A
General comment: Sizable amount of non-iodized salt imported from Kazakhstan and Uzbekistan
Mongolia 2,472 12,360 BCZS (processing), 480 no no N/A Imports
Ulaanbaatar iodized salt
Mon-davs (processing), 1,560 self- N/A Grinder Salt obtained
Ulaanbaatar manufactured and from licensed
polybags harvesting in
by UNICEF Dornod
Aimag
Local sources 300 – 500
General comment: Numerous natural salt deposits in 8 Aimags serve 30-40% of population needs. More than 50% of salt imported
Tajikistan 6,374 31,870 Koni Namak, Asht 15,400 continuous 1,500kg N/A Produces
spray (1999 and also "Extra"
machine 2000) salt
Khudja Mumin, Voce 18,500 continuous N/A N/A
spray
machine
Namaki Yovon, Yavan 3,700 yes, Glotra 4,500kg N/A Produces
(1999 and "Extra" salt
2000)
General comment: Tajikistan is self-sufficient in salt. Exports to Afghanistan, Kyrgyz Republic, Uzbekistan
Population Reported Information of donor (UNICEF, etc)
size, mid Estimated salt Major salt industry production edible salt assistance before 2001
2000* supply need or supply (processing) production Iodization Potassium Other Other
Country (thousand) (MT/annum) sources (MT, 2000) technology iodate (kg) donations comments
27
Population Reported Information of donor (UNICEF, etc)
size, mid Estimated salt Major salt industry edible salt assistance before 2001
2000* supply need production or supply production Iodization Potassium Other Other
Country (thousand) (MT/annum) (processing) sources (MT, 2000) technology iodate (kg) donations comments
Uzbekistan 24,760 123,800 Khoijakan Tuz, Surkhandarya 17,670 2 continuous 2,000kg Lab Largest mine
Oblast spray chemicals in the country
machines
Karakalpak Savda, RKK 2,500 continuous 1,000kg
spray
machine
Bakhtli Pvt, RKK 1,700 continuous 300kg
spray
machine
AzDuz, RKK 1,300 self- N/A
manufactured
Uzbekbirlashuw, RKK N/A N/A 1,000kg
Elektrokhimprom, Navoi 2,700 continuous 1,000kg
Oblast spray
machine
Sardarbek Pvt N/A continuous N/A Start-up in
spray 2000
machine
Kuvonch Pvt, Khorezm N/A continuous N/A Start-up in
Oblast spray 2000
machine
Tempo Joint Venture, 1,300 self- 200kg
Tashkent manufactured
TuzTaminot, Tashkent N/A continuous 2,000kg Start-up in
spray 2000
machine
General comment: Several new salt enterprises are "up and coming", and add to a mixture of Government-owned and private enterprises
* State of the World’s Children and Women, UNICEF, 2003
28
1. Decisions on input supplies for salt iodization
68. The guideline provided by ADB for development of CIPs had spelled out in detail
the kind of inputs eligible for funding under the JFPR grant. The country working groups
had made inventories of the national needs in response, which had been reviewed for
feasibility at the Almaty Forum and consolidated in a final CIP by end February 2002.
Further consultations with industries and EAs in each country had taken place during the
missions by Mr. Varghese. To achieve the best cost-effective approach, it was decided
that the in-kind support would be consolidated across countries and obtained via a
centralized tender procedure to be managed by RCAO. Numerous proposals were made
by the salt producers in all countries for improvements in salt production technology, but
the use of grant funding did not envisage investments in strengthened production but in
improved quality. Salt industries were also keen to develop more modern packaging,
with the aim to better serve their consumer markets. This desire aligned well with the
programmatic need for providing consumers with information about iodized salt, since
the packages are a known effective information dissemination source.
69. For each country, the CIPs had committed to achieve that the national salt supply
would be iodized to at least two-third of the population’s consumption by the end of the
project period. As can be readily seen from Table 3, these targets had to be pursued by
an approach that depended on the specific salt supply situation in each country. For
example, the capacities for salt production and processing in Azerbaijan, Kyrgyz
Republic and Mongolia were not sufficient to achieve the target by domestic sources
alone and in these countries, therefore, a significant part of the national efforts needed
being focused toward changing the imports to iodized salt. In contrast, the aggregate salt
production capacities in Kazakhstan and Tajikistan were sufficient to raise the iodized
salt supply to the population by an entirely domestic focus. These considerations, with
the approximate shortfalls of supplies for each country, were reasons for the variable
amount of salt iodization inputs (equipment and KIO3 fortificant) that were decided (Table
5) to be provided via centralized ADB procurement. The amount of potassium iodate
varied from as little as 200kg for Mongolia to almost 4MT in Uzbekistan. Uzbekistan was
also the major beneficiary of iodization equipment, 12 machines out of a total of 19. In
addition, out of a total of 50 salt companies, 17 were provided with packaging
equipment, mostly for 1kg packaging. Polypropylene salt bags and polyethylene film rolls
(used with the packaging equipment) were a substantive part of the total package also.
Table 5: Support by JFPR9005 for Physical Inputs to Raise the Iodized Salt
Supplies by Country
JFPR9005 Support
Country Number of Potassium Iodization Packaging Packaging Total
Beneficiary Iodate (MT) Equipment Equipment Supplies Costs*
Industries and Supplies (US$)
Azerbaijan 3 0.30 1 3 Salt bags 61, 410
Kazakhstan 2 3.25 1 1 Salt bags 76, 410
Kyrgyz 7 1.00 3 2 Salt bags and film 75, 406
Republic rolls
Mongolia 22 0.20 - 4 Salt bags 61, 306
Tajikistan 3 1.15 2 2 Salt bags 90, 116
Uzbekistan 13 3.90 12 5 Salt bags and film 268, 651
rolls
Total 50 9.80 19 17 633, 299
* Including installation costs
29
70. At the time of purchase, the amount of potassium iodate for each country was
calculated as sufficient for a production period of 1.5 year, roughly equivalent to the
remaining project period and enabling each country to achieve the iodization target of
66% of the national iodized salt supply. Noteworthy, in addition, was that each EA
entered into an agreement with the salt industries that each beneficiary industry would
reimburse one-third of costs of the fortificant provided. In Tajikistan, the industry was
exempted from this due to the seriously depressed economic situation in the aftermath
of civil war. The potassium iodate was supplied to the JFPR countries by early 2003,
followed by the equipment for iodization and packaging during the next few months. The
on-site training, installation and test-running were part of the purchase contract, but the
beneficiary salt companies themselves had a major role in ensuring the appropriate
coordination of the new equipment with the ongoing production processes. By and large,
the inputs were all in place, and operational, by October 2003.
2. The first 12-months’ period of JFPR9005: October 2001–September
2002
71. In the project countries, the 12 months’ period following upon the Almaty Forum
2001 was characterized mainly by efforts of the EAs to establish the arrangements
among the different partner organizations for effective project execution, and by the
stimulation of functional relationships among EAs, their CPO’s and the RCAO. During
the same 12-month period, a series of mini Round Table workshops was held in quick
succession with the overall aim of improving the technical capacities for activities that
support and stimulate the expected increased fortified food supplies and consumption.
This section presents these events and efforts in alternating succession to preserve the
chronological order and illustrate the multi-faceted character of the project.
3. Getting organized nationally
72. On return from the Almaty Forum, the Ministries of Health allocated a moderate
office for the project staff (i.e., the Country Project Office, or CPO) and started action to
manage a project account with the Ministry of Finance, establish a multi-sector Steering
Committee and open the communications channels on execution of the agreement with
ADB. As national EA, each Ministry of Health had committed to broad participation in a
Steering Committee (Figure 5) by including also the private salt and flour industries and
NGOs that are addressing the food supply and the consumer concerns, whose interests
would complement those of the scientific community and the public authorities already
dealing with issues of food supply and consumption in the population. While the idea of
food fortification—especially salt iodization- was not new in any of the JFPR countries,
the newly promoted approach of consideration and decision-making in partnership on
priorities and responsibilities for project activities took some time to be appreciated and
embraced. And in some countries, this process took longer time to be initiated and take
hold than in others.
30
Figure 5: A Steering Committee meeting in Astana, Kazakhstan
73. Also, Expert Working Groups were formed to assemble subject specialists
around special topics, such as: Selection and introduction of flour fortification
technologies (Kazakhstan), Roll-out of communication campaigns (Kyrgyz Republic,
Kazakhstan), supply and consumption monitoring (Mongolia), and so on. Generally, the
theme groups were meeting more frequently, especially around the times that there was
much action on a particular need. The Steering Committee meetings were of a more
periodic nature, thus ensuring that the different partners could participate at high-level
while the burden on their valuable time was kept in acceptable limits.
74. The establishment of appropriate administrative and financial procedures for
project execution in each CPO was supported by a regional workshop for CPO project
personnel, held in Bishkek, 4-5 March 2002 and facilitated by ADB and RCAO staff. The
project personnel in each country’s CPO consisted of a project manager and a finance-
administrative assistant. Eventually, each CPO was housed in a modest office and
equipped with a dedicated phone line for convenient communication among all the
offices, the RCAO in Almaty, the KAN and the larger world. Financial accounting and
reporting of the project inputs, activities and expenditures was also strengthened during
the Bishkek workshop and aligned to the needs of transparent donor-recipient
collaboration. Notably, the CPO personnel of Azerbaijan could not take part in this
workshop due to the delayed signing of the Letter of Agreement (LoA) on JFPR9005
participation between the Azeri Government and ADB.
D. Advocacy, communications and social mobilization: Mini Round Table in
Bishkek, February 2002
75. In February 2002, a Communications/Social Marketing mini Round Table was
held in Bishkek, Kyrgyz Republic, with overall facilitation by Gary Gleason of the
International Nutrition Foundation (ADB consultant) and Fatima Djatdoeva, a free-lance
communications expert working from Moscow who was contracted by UNICEF. From the
outset of the JFPR project, it had been clear that the communications in support of
fortification should reach beyond the effort to work only on effective purchase by
consumers and also include work to advocate at high political levels and change the
attitudes in favor of fortification among influential stakeholders of technical decisions and
public opinions. Moreover, the core purpose of increasing the fortification in food
productive industries by promotion of mandatory legislation obviated the requirement for
31
convincing the consumers to make the right choice between a fortified and non-fortified
commodity. Thus, the overall aim of the communications action plan became to raise
and achieve broad acceptance in society, by making sure that the key gatekeeper
groups were informed and supportive, and that influential advisers and decision-makers
supported the value and safety of the new products to be fortified.
76. The communications strategy called for an adaptation in each country of a
generic multi-level model, with simultaneous three-tiered attention to (a) Advocacy and
resource mobilization, (b) Alliance building and organizational motivation, and (c)
Community information, education and communication. Funding and technical support to
follow through on this model was available from the JFPR grant in each country,
complemented by UNICEF support from country offices. Critical to the roll-out of
communication campaigns in each country were contributions from volunteers largely
though community-based action, and from private sector marketing via product sales
channels.
77. The mini Round Table in Bishkek also initiated an area-wide initiative for
documentation of activities and lessons learned, managed by the Kazakhstan Academy
of Nutrition (KAN) and the Regional Coordination and Administration Office (RCAO). The
latter effort generated the materials and information of the JFPR regional food
fortification project that were posted regularly on a website, devised and maintained by
KAN.
78. The Bishkek mini-round table mobilized follow-up action in each country. To
illustrate, the planning in Kazakhstan was facilitated by close collaboration among the
CPO and UNICEF in preparing and attracting an experienced public health
communications expert of CDC, Galen Cole, who worked together with Fatima
Djatdoeva in managing a national workshop in July 2002 that assembled the broad array
of national stakeholders in developing a detailed plan for the national communications
campaign. A study in 2001 on “Knowledge, Attitudes and Practices” conducted by the
National Center for Health Promotion (now renamed to National Healthy Life-Style
Promotion Center) had revealed serious gaps in the population’s and health providers’
knowledge on the issues of iodine deficiency and its prevention. The communications
plan used the results of this study and specified specific behavior-influencing tactics,
based on several stages and various channels, for a wide range of target groups to
achieve defined knowledge and behavior targets, along with the communications
concepts and associated messages that would be used upon pre-testing with the
specified target groups. The workshop also initiated a Technical and Implementation
Group (TAIG) and a Communications Coordination Committee to whom the TAIG
reported. The TAIG, composed of the partners that were involved in executing the plan,
developed the implementation schedule with a time frame and allocated concrete
responsibilities and reporting requirements. Although the planning process was most
comprehensive and involved in Kazakhstan, national communications planning was also
started in the Kyrgyz Republic, Mongolia and Tajikistan at around the same time.
1. RCAO support missions, 1st round 2002
79. At the time that national communications campaigns were being initiated by the
Bishkek mini Round Table and further developed by national follow-up actions, RCAO
started to pay visits to each country with the dual purposes of assisting the CPO
managers and EAs to accelerate the expected broad, multi-sector approach and develop
32
the CPOs’ capacity for administrative and financial management of the JFPR support for
serving both the donor’s needs and the national requirements. The 1st round of RCAO
support missions took place from late January to end May 2002. Not surprisingly, the
progress in response to the plans made at the Almaty Forum was different in each
country. At the time of each visit, all EAs had signed the LoA, followed by agreements on
a project administration memorandum except in Azerbaijan. National Steering
Committees were functional in Kazakhstan and Mongolia, but the arrangement for
composition, mandate and rules of conduct were either ongoing or had just been
initiated in the other countries. In Azerbaijan, the space for a CPO office was yet to be
decided and in Tajikistan repairs were needed to enable the CPO to move into the
allocated office space. Due to the dispersed salt industry, effective participation by salt
producers in the decision-making and in communications activities was difficult to
arrange in Mongolia. In Uzbekistan, follow-through on the agreements stated at the
Almaty Forum had to contend with an extraordinary elaborate bureaucracy. Moreover,
the involvement of the salt industry in Uzbekistan appeared to be subject to the
authorization of each individual company by the inspection authorities. The discussions
among partners in Kyrgyz Republic and Tajikistan about a waiver of the import tax on
essential inputs for salt and flour fortification had ran into fierce opposition by
International Monetary Fund (IMF) advisors. Each visit was geared also to stimulate
appropriate local NGO partners, especially for involvement in the communications
campaigns. During each visit, the RCAO also initiated a discussion on the Government’s
willingness to purchase fortified foods as part of ongoing social support programs. This
recommendation was generally met with goodwill and endorsement. In all countries, the
need was apparent for capacity development of food inspectors.
E. Legislation and regulation: Mini Round Table in Tashkent, June 2002
80. There was clear understanding early on among the RCAO and CPO managers
that a major purpose of the advocacy and technical assistance would be to strengthen
the political will for a principal law that would compel the production and import of only
fortified food, and for regulations to define the agreed methods, norms and procedures
to ascertain and maintain product quality in the supply channels from the production to
the consumer and export markets. To reach the full constituencies for national legislation
and regulations, a mini Round Table was held in Tashkent, Uzbekistan in June 2002.
This meeting brought together more than 60 participants from the six participating
countries working in Government, the salt and flour industries, the food control agencies
and SES services, technical metrology and standardization committees, the CPO’s and
ADB and UNICEF expert consultants.
81. The mini Round Table on Food Fortification Standards, Regulation, Quality
Assurance and Control had a range of related objectives, encompassing the concerns
among partners to ensure and maintain the quality of fortified foods throughout the
processes of fortificant sourcing and purchase, product manufacturing, processing and
supply, to marketing, storage and retail. At the Tashkent mini Round Table, industry
participants were informed on the required preparations in the selected enterprises
before the receipt of project-sourced machinery, fortificant, packaging and QA related
equipment. Also a new iron-folate premix formula developed in close collaboration with
ADB consultants by the KAN (named KAP #1 complex) was introduced and discussed
extensively. Finally, leading scientists of KAN shared information of the design and a
proposed schedule for the Sentinel Studies—a coordinated scheme for food
consumption and biological outcome studies aimed at capturing the operational
33
effectiveness of salt and flour fortification on the nutrition status of small selected groups
of household members in the pilot areas of each country.
82. Two technical groups worked in parallel fashion for two days during the Tashkent
mini Round Table on model work plans for the acceleration of comprehensive QA
systems for iodized salt and fortified flour production, supply and consumption. The
recommendations from these groups provide clear testimony of the raised awareness
and understanding among participants that the required enactment in each country of a
mandatory fortification law should be accompanied with equally important follow-up
action to establish effective QA capacity in the productive industries and functional QC
capacity in the food control agencies. The model work plans also were a first indication
of the diverse regulatory standards that needed to be formulated and agreed for
translating the new legislation into transparent and mutually agreeable norms of conduct
in input sourcing, fortified food inspections, local trading and export transactions.
83. The mini Round Table concluded with a detailed outline of needed activities,
covering the legislation and QA steps, the planning for a 1st round of the Sentinel
Studies, and the finalization of the central procurement for salt iodization inputs and QA
supplies. ADB, RCAO, CPO’s and KAN agreed to develop specific joint action plans in
consultation with national parties, culminating in final, agreed-upon, joint action plans in
each country by September 2002.
1. Healthy Food Logo
84. Typically, the purpose of a logo is to increase the appeal of a product to
consumers on basis of easy and immediate recognition. A logo is designed to inspire
admiration, trust and loyalty - even implied superiority. The practice of using logos was
already common for Western products in participating countries, but they had not been
commonly introduced for locally manufactured products in the area at the time the
project started. The idea of developing a logo was conceived at the time of the mini
Round table on Communications and Social Marketing in Bishkek, and specialists of
KAN were tasked with its prototype design, the pre-testing and final roll-out. Importantly,
a decision was made to support a logo that would be common for all fortified products,
thus serving the dual purposes of properly identifying all products that were fortified
under mandatory rule but also promoting those products that were fortified by a
voluntary effort in the food industry.
85. The development of the logo was coordinated by KAN by issuing an invitation via
the networks of artists and designers to submit a prototype to the Kazakh Press Club,
which had been chosen on basis of a tender as the PR company for the national
communications campaign. Working with professional graphic designers, the KAN
specialists went through several iterations of prototypes, each time pre-testing the
opinions of different respondent panels and eventually ending up with a design that
conveyed a simple, positive and joyful impression to the large majority opinion of
respondents.
86. The final logo (Figure 6) was ready to be shared with CPOs by August 2002 for
their extension in countries.
34
Figure 6: Health Food Logo of each Country
Kazakhstan Kyrgyzstan Mongolia Tajikistan Uzbekistan
87. The Joltai Design Studio, Kazakhstan, prepared special guidelines for the proper
use of the logo, which were shared by KAN with all CPO’s at the time of the mid-term
review in Astana, October 2002. Recommended measures by food control agencies to
safeguard against its misuse on counterfeit products (the labeling states the product has
been fortified, but in reality it has not) were included in the guidelines.
2. Project website
88. Also starting in the first year, KAN and RCAO were collaborating on the design
and development of a project website. The role of KAN experts was focused primarily on
the collection and editing or, if needed, writing of new informational materials in Russian
and English, the solicitation and quality control of inputs contributed by CPO’s on
ongoing activities in the participating countries, offering inputs in various drafts of a
regional and country-specific web pages, and making contributions of texts and images
on ongoing basis. RCAO had a major part in web site design and it also contracted the
service provider. The website, named www.caffproject.net, has been functional for
several years starting from early 2003. Many materials were moved to the ADB website
at the project’s end.
F. Mid-Term Review, October 2002
89. The JFPR9005 mid-term review took place on 4 October 2002, immediately
following the Round Table in Astana, with participation of two ADB officers, the RCAO,
KAN and each CPO. The CPO’s had prepared draft mid-term assessments according to
an agreed outline, and they presented the achievements and experiences for the past 12
months in a plenary session. It was noted that the planned activities under the social
mobilization component had been executed especially well in Mongolia and Tajikistan
while working closely with a range of NGOs in each country. Kazakhstan CPO had
started the roll-out of communication activities in collaboration with UNICEF, KAN and
the NGO Confederation.
90. The review made clear that the project was delayed in execution, mainly because
of optimistic time projections at the design stage in connection to the complex process of
international competitive bidding that involved coordination within and between six
countries. It was noted also that the CPO’s had no prior experience with the ADB
procedures and guidelines, and that many had run into management and staffing
problems. Factors of concern were the limited assumption of leadership by the EA in
some countries, and the difficulties encountered in adjusting the existent technical norms
and standards of conduct in product quality assurance and control, inherited from the
Soviet Union, to the modern standards that are promoted under the project. Considering
the realistic outcomes that could still be obtained from projections of the current phase,
35
ADB and JFPR had agreed to extend the project completion date to June 2003 for the
CPO’s and to March 2004 for KAN in view of the need for results from the Sentinel
Studies.
91. Agreed-upon directions on the priorities for the remaining period were as follows:
(i) Enactment of a principal USI law was one of the most important expected outcomes
of the project. In Azerbaijan and Kyrgyz Republic, USI laws are on the books but
they had yet not been effectively enforced in practice. In Tajikistan, a draft USI law
had been sent to Parliament for consideration. The Uzbek government seemed
misinformed as it had voiced an objection to USI legislation on the argument that it
would limit the “right of choice” of consumers. The drafting of a USI law had yet to be
initiated in Kazakhstan and Mongolia. The project will strengthen its support for
advocacy and provide technical support for actual drafting of USI laws in the three
countries that were behind schedule,
(ii) CPO’s had selected the salt factories for support under the Project on basis of the
reported production capacities. While in Kazakhstan, Tajikistan and Uzbekistan the
salt iodization target was achievable by iodization of the domestic salt production,
controlling the quality of imported salt was a major priority for Azerbaijan, Kyrgyz
Republic and Mongolia. The project will support capacity building for quality control
at main import entry points and support an operational study on illegal salt imports,
and
(iii) The targets for flour fortification were expected to be achieved in Kazakhstan, Kyrgyz
Republic, Mongolia and Uzbekistan by increasing the fortified flour production in
domestic flourmills. In Azerbaijan and Tajikistan, both heavily dependent on imported
grain, the project will focus on the imports for humanitarian aid to meet the target.
The underlying idea is that in coordination with donor agencies, grain aid can
systematically be sent to selected mills for fortification.
92. In view of the delay of project execution in the countries and the limited
expenditure incurred during the first 12 months, CPO’s were encouraged to work with
the EAs and collaborating partners in the countries to develop and submit adjusted CIP’s
and budgets with realistic targets for the remaining project period. The CIP and budget
adjustments were agreed to be ready by the time of the 2nd round of support missions of
the RCAO manager, planned for the next quarter.
G. The second period of JFPR9005: October 2002–September 2004
93. The experience during the first 12 months after the Almaty Forum 2001 had
made it increasingly clear that it takes time for the new multi-sector collaborative
approach to be understood, discussed and embraced among all the principal partners.
Moreover, upon realizing their specific roles and responsibilities, each sector needed
time to first work through its own issues before being ready to engage in joint decision-
making with others. As an example, the transparent, even-handed conduct of food
quality inspections in the sales channels, along with actions to enforce the agreed
standards, came to the fore in all countries as an issue needing training and
development of capacity. Also in those situations where the political willingness of EA
leaders was evident, the change from State directions toward joint decision responsibility
needed time to take hold. A related cause for delay, which was especially evident in
Azerbaijan and Uzbekistan, was that the EA needed to stimulate collaborative work
toward principle legislation and elimination of taxes and tariffs, which both needed
36
consultation and agreement among a range of national constituencies, some of which
voiced strong and different types of objections. A 3rd lesson from the early experience of
project execution was that the selection of salt and flour industries had often taken place
under political consideration, thereby slanting the beneficiaries mostly toward State-
owned or controlled enterprises.
94. Along with the agreements reached at the Almaty Forum 2001, the quick
succession of regional mini Round Tables had helped to clarify the new technical,
operational and funding opportunities of each country to realize significant increases in
the national fortified food supplies to enrich the common diet of the population. The
various mini Round Tables had stressed the need for a functional, multi-sector coalition
under leadership of the Ministries of Health, the requirement of a focus on product
quality as a principle to foster mandatory laws along with associated regulations and
normative requirements, and the importance of monitoring the processes as the basis for
informing the national oversight and decision-making approach that would drive
continued progress. The mini Round Tables had been organized around the three key
program components, namely: Communications, Monitoring and Fortification, while
emphasizing the importance of the existing linkages among these components. In short,
the JFPR9005 project’s guidance and regional meetings had invested in laying the
foundation for action that from now on needed to accelerate within the participating
countries to reach the targets of 66% iodization and 33% fortification of the salt and
wheat flour supplies, respectively (with a more ambitious target in Kazakhstan).
95. By design, the onus of initiating and executing action to stimulate increased
fortified food supplies became shifted toward the partnerships in the countries during the
second phase of JFPR9005. The process of international competitive bidding, managed
with coordination from RCAO in Almaty, was near completion and the investments in
equipment and fortificant were about to arrive. In the countries, follow-up action had
been started to a varying extent in planning for communication campaigns, drafting and
consultation of national legislation and regulations, improving the quality control and
enforcement practices, and preparing for the installation, commissioning and use of the
equipment and fortificant supplies in the salt and milling industries.
96. At around the time of the mid-term review, a noteworthy event in Uzbekistan was
the national multi-sector meeting, organized jointly between ADB and UNICEF and
especially directed at the salt producers on the justification and requirements for
achieving USI. The more than 50 participants hailed from the salt industry (18
manufacturers were represented) and a host of medical professionals and government
officials. Held during 24–25 October 2002, the meeting learned of the delays in the
progress toward the USI goal and agreed to make stronger efforts to take advantage of
the new technologies for iodizing salt. The meeting spent the 2nd day deliberating on a
draft law proposal for USI and enforcement of iodized salt standards, and discussed the
formation of a Salt Producers Association. The resolutions from the meeting included the
agreement to adopt the standard in the industry of the iodization level of 40±15 mg/kg,
as recommended by WHO and UNICEF, and already being practiced in other CIS
countries at that time.
3. RCAO support missions, 2nd round 2002-2003
97. The RCAO manager conducted a 2nd round of support missions from November
2002 to February 2003 to further assist the EAs and CPO managers in the agreed
37
collaboration in national project execution, discuss the efficiency of the major project
components with high-level leaders in Parliament, Government, industry and NGO’s, as
well as address specific obstacles that had surfaced during the first year of the
JFPR9005 project. The visit to Uzbekistan was carried out in two stages, the first one in
November 2002 being largely dedicated to help resolve a serious delay in customs
clearance of a sizable shipment of project supplies. In all countries except Azerbaijan,
the EAs had booked evident progress in carrying out the agreements made at the
Almaty Forum 2001 and had entered into a collaborative relationship with the salt and
flour industries, NGOs and other partners. A Steering Committee with a CIP, a national
strategy and a work plan were in place to variable degrees in all countries to utilize the
opportunities offered through the JFPR9005 funding.
98. The support mission in early November to Azerbaijan was the first of the support
visits by RCAO after the Mid-Term Review in October 2002. The interviews and
discussions with parliamentarians and officials of other ministries made it clear that the
EA had yet to step up to an inclusive leadership role. Also the performance of the CPO
in devising a new work plan and budget revision had fallen behind due to a combination
of rapid turnover of the administrative staff and the mainly clinical background of the
office manager. The EA had not yet initiated the collaborative drafting of a USI law, the
outreach to community organizations, or proposals to address the structural reforms in
taxes and tariffs on fortification inputs and products. RCAO reached an agreement with
Parliamentarians that a National Consultative Conference would be held in early 2003 to
address the issues of the required inclusive multi-sector approach, the drafting of
legislation, regulations and standards, and the initiation of activities toward tax and tariff
elimination and social mobilization. Support for the approach was obtained from
UNICEF, NGOs and industry partners. A factor that hindered the smooth execution of
the agreements in Azerbaijan was the ongoing power struggle on the authority for
national decisions and enforcement between, on the one hand, the Office of the
President, and the Parliament and Government line Ministries on the other.
99. In Mongolia (allocated CIP budget $850,000), the EA, CPO and Expert Working
Group had made headway in launching a communications campaign to promote
acceptance of fortified flour, starting in Ulaan Baatar. The KAP complex standard had
been adopted, a draft USI law was being developed on request by the President, six
flour mills and 22 salt enterprises had been identified for input support, and AIC had
already completed the installation of feeders for flour fortification (Figure 8). At the time
of the RCAO visit, the food quality inspection system was being reorganized into a single
Specialized Agency thus limiting the capacity for focusing on ensured quality inspection.
A proposal by the Ministry of Agriculture (Deputy Chair, EA) for iodization inputs had not
yet been finished, and in discussion with the EA, it was agreed to focus JFPR assistance
on efforts to improve the quality and amount of iodized salt supplies from two
strategically selected sources in Western Mongolia. RCAO also offered to provide
international opinion on the draft USI legislation.
100. The agreements in Mongolia for the immediate future included that a Salt
Producers Association would be established, the NGO role in the communications
campaign strengthened, and further efforts would be focused on monitoring activities of
the fortified food supply as well as their consumption and population biological status as
part of the Sentinel Studies coordinated by KAN.
38
101. Also in Kyrgyzstan (allocated budget $700,000), the EA, CPO and Expert
Working Group were established, nine flour mills and seven salt enterprises had been
selected, the KAP complex standard had been adopted, and SES had started with
improving the food quality inspections upon direction from the President. A
communications campaign was under preparation, four of the seven feeders delivered
under the project had already been installed, and the access to non-iodized salt had
reportedly been eliminated from the local markets in Naryn Oblast at the time of the visit.
The leakage of non-iodized salt in to the national markets remained a major issue in the
Kyrgyz Republic, however. It was agreed that the Institute of Strategic Research, under
the President’s Office, would conduct a special in-depth study of the situation. As
mentioned before, the proposals to waive tax and tariffs of future imports of fortification
inputs were meeting with strong resistance by IMF advisors in the Ministry of Finance.
Another issue of concern was the “temporary cancellation” of fortification practices in the
State-owned flour mills, which was said to be due to shortages of wheat grain supplies.
In the private flour mill Akkun of Bishkek, however, fortification was ongoing without
interruption. General agreements included that the preparations for a communications
campaign would be stepped up and include a broad array of NGOs in the various
Oblasts; that the discussions on taxes/tariffs would be elevated to higher political level;
and that more efforts would be directed toward capacity building of the food quality
inspection systems.
102. The two-staged missions to Uzbekistan (allocation of $1,200,000) demonstrated
limitations of CPO capacity in project execution and management. It was also apparent
that the EA had thus far been acting largely in isolation: For example, in November 2002
the project partners had not yet been informed of the progress report that had been
presented at the MTR the month before. In addition, the Expert Working Group tended
not to use the full range of expertise available in the country. A third admin/finance
assistant had been appointed and needed special training from RCAO, which was
conducted in December 2002. There was serious delay in customs clearing of project
donations in November due to an improper request for tax exemption by the EA, but the
delay had been resolved by February 2003. In December 2002, the Vice-Premier of
Uzbekistan chaired a special Steering Committee meeting with the aim to address the
underlying issues of collaboration. The EA was instructed to assume true leadership,
being inclusive of the full range of partners and expertise in the country, and no longer
remain in a reactive mode. The EA was to initiate the processes for eliminating the
tax/tariffs on future fortification inputs; start consulting international expertise for the draft
USI law that was being reviewed at that time by 21 Ministries and Government agencies;
work with a range of NGOs in the communications campaign; expand the Working
Group beyond only the health profession; and, finally, strengthen project monitoring. In
February 2003, 38 feeders and 89MT KAP premix had been received, but no fortification
was ongoing due to “temporary lack of quality wheat grain”. Also, a communications
campaign had been launched in pilot regions, and the KAP standards had been agreed,
although the salt iodization level agreed in Minsk in May 2001 (40±15mg iodine per kg)
had still not been adopted officially in Uzbekistan.
39
Figure 9: Laboratory in Oz’Fant Salt Enterprise, Jizak, Uzbekistan February 2003
103. At the time of the RCAO visit in February 2003, the Ministry of Health started
recommending the Oz’Fant State Company (Figure 9) in Jizak pilot area for inclusion in
the project. Oz’Fant’s Director explained that the National Salt Producers Workshop in
October 2002 had not been followed-through due to frequent changes in small salt
enterprises, combined with lack of experience in the sector, and he agreed to push for
negotiations on a second Salt Producers Meeting in 2003. The agreements with RCAO
included that the CPO should present a revised work plan a.s.a.p. to ADB and
coordinate with UNICEF to thoroughly review the comments on the draft USI law
proposal. The EA would hold a working meeting with salt producers to review the draft
USI law proposal, discuss the issues of delay in starting salt iodization and press for
establishment of a Salt Producers Association. EA would also conduct expert
consultation on the reasons for delay in starting flour fortification, pricing issues for
fortified flour, and the linked initiation of proposals for tax and tariff elimination.
104. When in February 2003 the RCAO conducted the support visit in Kazakhstan
($900,000 funding allocation), a management system among the EA, CPO, Steering
Committee and Expert Working Group were functioning well. The President had issued a
directive to facilitate food fortification and adopt the KAP premix for flour milling, and a
national workshop on wheat flour fortification had discussed the required technical and
operational issues in collaboration with the League of Grain Processors and Bakeries in
Kazakhstan (LGPBK). The EA had identified 15 flour mills and two salt producers for
support under the project; a draft USI law was under consideration in Parliament; and
efforts were ongoing in SES for improving upon the existing food quality control and
enforcement practices. The issues discussed during the RCAO mission included the
coordination in pressing for the elimination of taxes and tariffs on the future import of
fortification inputs and cross-border trade in fortified foods; the stimulation of government
purchase and control of sales prices of fortified foods in the pilot Oblasts; and the
ongoing clarification of the project-provided equipment for flour fortification. It turned out
that the pilot mill Tsesna Astyk had obtained positive experiences with the use of the
AIC-manufactured one-stage equipment. The Tsesna Astyk Company, as well as the
AralTuz Salt Company had initiated marketing and promotion of fortified salt and flour
through their own sales channels but results of these efforts could not yet be assessed.
The discussions with the Confederation of NGOs revealed that a range of local NGOs
had been mobilized for the roll-out of the draft communications campaign in pilot Oblasts
Kyzl Orda and South Kazakhstan. The EA and CPO were in agreement with the short-
term priority focus on further stimulating the adoption of the USI law in Parliament;
40
accelerating the reforms in SES food quality control practices; and closer coordinating
the communications campaign roll-out, while emphasizing the assessments on evidence
of (fortified) food purchase behaviors in communities.
105. When RCAO visited Tajikistan ($700,000 budget), the Ministry of Health was
being reorganized at the direction of the President. The Government structure
reorganization also affected other Ministries, leading to a revision of members in the
Steering Committee. On passage in Parliament, the President had ratified a Law on IDD
prevention on 22 December 2002; seven flour mills and three salt enterprises had been
identified for support under the JFPR project; and the consideration in Government of
tax and tariff elimination was awaiting the submission of justifications by the EA. A
communications campaign had been started in Dushanbe and pilot regions. Although
the CIP and the budget had been revised, a new CIP work-plan was still pending. It
appeared that a discussion with donors on waiving Tajikistan’s outstanding debt was at
the background of the Government reorganization effort. Discussions were held with the
State Revenue Office and the Office of the President on tax and tariff elimination, and
the exemption of Tajikistan to repay part of the granted fortificant. The Ministry of
Finance, however, continued its resistance against permanent tax and tariff elimination
on the grounds of “IMF policy”. Agreements were reached that EA would submit the
revised work plan to RCAO shortly; the Ministry of Economy and Trade would report on
the status of flour fortification in mills previously equipped by UNICEF support; the
Ministry of Health would stimulate improvements in SES practices of food quality control
and enforcement; and EA would step up its inclusive coordination of activities in
communications, price monitoring and community mobilization in Kathlon pilot Oblast.
106. In summary, the 2nd RCAO support missions to the participating countries
exposed a significant variation in political will and operational capacity to follow-through
on the agreements of the Almaty Forum 2001. The EA in Azerbaijan had yet to assume
ownership and show willingness to adopt the leadership role, while the EA role in
Uzbekistan had been shored up through a direct intervention by the Prime Minister’s
Office. The EA in other countries had assumed the inclusive leadership role earlier, but
the results in terms of actions that had been mobilized and accelerated among partners
and within the Government’s structures differed by country. More attention was required
in all countries to ensure full and meaningful involvement of NGOs in the
communications campaigns. The progress in adopting the fortification practice in flour
mills was feeble, thus indicating the need for stronger actions among partners to
stimulate increased supplies and acceptance in the sales channels. Also, the need
across the board was evident for efforts to strengthen the local capacity in quality
assurance and in keeping fortified products affordable. And finally, a consensus on tax
and tariff elimination had to be more actively pursued in all countries.
4. First Round of Sentinel Studies: December 2002–April 2003
107. At the Almaty Forum 2001, the need was recognized by the project’s leadership
for information of the effectiveness of increased fortified flour and salt supplies on the
dietary consumption and key biological outcomes in the targeted population of the
participating countries. Professor Scrimshaw, the principle external advisor, came up
with the novel idea of selecting “sentinel” sites in targeted poor areas of each country for
tracking the public awareness, fortified food supplies and biological effects in selected
vulnerable groups of the JFPR participating countries. KAN was requested to collaborate
with local counterpart nutrition institutions and UNICEF in conducting small-scale studies
41
in households of pilot areas in each country. The general design was to first obtain a
baseline situation prior to the planned increase in fortified salt and flour supplies, and
then repeat the studies in each sentinel site at intervals of one and more years after
fortification had been introduced. Households were selected purposely in the pilot areas
of each country, meaning that the study groups were typical for poor populations that
were targeted by the increased fortified food supplies.
108. The 1st round of Sentinel Studies, providing a baseline for future comparisons,
took place during the period December 2002–April 2003 and focused on key indicators
of the iron, iodine and folic acid status among children aged 2–15 years, living in 40
urban and 40 rural households. The hemoglobin content in capillary blood was
measured by a HemoCue® apparatus, enabling immediate feedback to the participants.
A special questionnaire was administered to collect data of the female head of the
household on her knowledge, attitudes and practices of fortified food use, and samples
of blood, urine, flour and salt were collected from each household for analysis in either a
reputed national counterpart laboratory or in the KAN laboratory. State-of-the-art
laboratory procedures were employed and KAN organized an external quality check on
the serum ferritin and urinary iodine assays in the counterpart laboratories. All the
plasma folic acid determinations were performed in the KAN laboratory. Throughout the
rounds, a special effort was made to revisit the same households and the same data
collection procedures were maintained.
109. In spite of the considerable operational constraints in the execution of the three
study rounds in each country, the data collected from the Sentinel Studies in the course
of the JFPR projects constitute a rich and unique source of information about the
duration and extent of changes in dietary knowledge and behavior, and the subsequent
improvements in fortified food consumption and biological status. The results of the
Sentinel Studies will be reported in a later section to enable a perspective of the events
that took place in time and their associated effects in the various countries.
H. JFPR Project Implementation: Mini-Round Table in Bishkek, April 2003
110. This 3-day meeting, held immediately after the 2nd round RCAO support visits,
assembled a selection of the principal stakeholders of the JFPR projects in the six
participating countries (members of the Steering Committees and Expert Working
Groups, with emphasis on food quality control agencies) together with the CPO and
RCAO managers, ADB officers and KAN, UNICEF and ADB expert advisors to consider
the critical issues in national fortification policies and monitoring and evaluation, along
with parallel attention to JFPR-specific guidelines for project execution, auditing and
reporting. The meeting thereby represented both a capstone on the quick series of Mini
Round Table meetings as well as a future roadmap for obtaining the most optimal
benefit from the JFPR project resources.
111. Using the experiences gained during the past 18 months, national project
stakeholders presented examples of “good operation practice” in fortified food production
and supply; elaboration and establishment of national laws and standards; improvement
of product quality assurance, and food inspection and enforcement; community
awareness building and mobilization; and tracking of project inputs, actions and
outcomes. For example, a Salt Producers Association had very recently been
established in the Kyrgyz Republic, thereby enabling the diverse salt enterprises to
speak with a single voice in the Steering Committee for representing their common
42
interest. Another example was that all countries had either already adopted or were in a
process of considering a draft USI law, while similar wheat flour fortification frameworks
were being introduced. In improving the practices of food quality control and inspection,
it had become increasingly critical to establish the capacity for independent verification
by a national reference laboratory that could also function to support the development of
industry-based quality assurance practices. Finally, communications campaigns to
promote acceptance of fortification among the politicians, professionals and the public
were being conducted in all countries and the 1st round Sentinel Studies had just been
completed in all six countries. The next project period was positioned as the most critical
phase for establishing national systems for comprehensive prevention and control
activities in the long run.
112. The mini Round Table in Bishkek took stock of the detailed situation of JFPR
project execution in each participating country by the presentation and discussion of
reports prepared by CPO managers. As noted before from the situation analysis during
the RCAO visits, sizable variation in achievement was apparent among the countries,
related to various factors. A main issue in most counties was the prevailing Government
attitude and political will for joint collaborative responsibilities, which came to the fore in
the mandate and performance of the Steering Committees. The prevailing situation was
illustrated at the meeting by the following matrix to help reminding all partners of the
tasks ahead (Table 6).
Table 6: Progress Assessment Matrix at mid-JFPR9005 period, April 2003
Quality
Flour Social
Salt Iodization Legislation Assurance
Fortification Mobilization
and Control
Tangible progress
Kazakhstan Kazakhstan Kyrgyz Republic Kyrgyz Republic Mongolia
Kyrgyz
Mongolia Tajikistan Kazakhstan Tajikistan
Republic
Uzbekistan Kazakhstan
Kyrgyz Republic
In progress
Tajikistan Tajikistan Kazakhstan Mongolia
Uzbekistan Azerbaijan
Azerbaijan
Little or No progress
Mongolia Kyrgyz Republic Uzbekistan Tajikistan Azerbaijan
Uzbekistan Mongolia Azerbaijan Uzbekistan
Azerbaijan
113. The mini Round table reaffirmed the commitments in all countries to achieve the
goals of the JFPR project and it consolidated the understanding among the principal
national stakeholders and project managers of the ways and means afforded by the
project resources to achieve those goals. Also, the meeting had offered the participants
a clear understanding of the activities to be accomplished, the lessons of successful
examples of management practices, and the efforts to promote sustainability. Also the
participants endorsed the need for an extension of the project period to complete the
agenda of activities and ensure achievement of the objectives.
43
I. JFPR9005 Strategy implementation
114. As indicated before, the second JFPR9005 phase from early 2003 onward was
dedicated primarily to actions and activities in the participating countries. The next
section, therefore, describes mainly a number of noteworthy developments, events or
actions of a more national character to illustrate the overall efforts to realize
improvements in the fortified food supplies in Central Asia and Mongolia. In the course of
time that the second JFPR9005 phase unfolded further, it became even more obvious
that the expectation of swift and successful adoption and acceleration of fortification in
the salt and flour industries, and buttressed by supportive actions in the Government and
other partners in the time frame of about 2 years was not realistic. The slow progress in
executing the national fortification strategies meant also that the expenditures from the
JFPR budgets fell behind schedule. Moreover, since the achievement of project
benchmarks had been formulated in terms of evidence of actual fortified food supplies, a
delay could be foreseen in the ability in each country to show data from the salt
production and flour milling industries to demonstrate that the project was meeting the
agreed goals. These factors in combination were underlying a decision to explore the
possibilities for further JFPR9005 extension, as well as a renewal of the regional JFPR
support in a follow-up project.
1. Communications campaigns
115. In Kazakhstan, immediately following national plan development, KAN with the
Healthy Life-Style Promotion center and selected PR firms produced draft educational
and communications materials for pre-testing in small focus-group interviews with their
specific target groups. Upon adjustment, these materials were tested for effectiveness
during the second half of 2003 in the pilot areas of South Kazakhstan Oblast. The full-
fledged schedule included the final development, production and distribution to different
target audiences and population groups of a set of communications materials on IDD
and anemia prevention, as well as press conferences, presentations, and training
seminars for NGO employees, mass media, and salt and flour product dealers together
with TV promotion to convey the advantages of using fortified foods. On salt iodization,
the communications test scheme was conceptually directed at promoting the preventive
effect of iodized salt use and it aimed to reach large population groups using the State
resources of the health care and education sectors, the mass media of the region and
NGO public organizations. It delivered numerous sets of 12 kinds of printed and video
products on iodized salt with specific messages (in the forms of leaflets, booklets,
brochures, posters, methodical manuals, comics, films and videos) to different target
audiences in the pilot areas. Target audiences included local authorities, salt enterprises
and traders, State employees in primary health care and sanitary services, in middle
schools, colleges and universities, young school children, teenagers and pregnant
women, mass media workers and the general public. Especially in rural areas, these
groups were enlightened on the dangers of iodine deficiency and the desirability of
consuming iodized salt, the principles of iodized salt storage and use during cooking,
with promotion of the general trademark of “Healthy Food/Sapaldy Azdyk”. At the end of
2003, assisted by JFPR and the Kyrgyz representative office of Red Cross, monitoring
surveys and population interviews were conducted on the quality of iodized salt among a
total of 90,995 rural and urban households in South Kazakhstan Oblast. The result
indicated that the awareness of IDD and use of iodized salt among the population had
improved from 43% to 61% during the effectiveness test. Virtually all respondents had
heard about iodized salt; 95% of respondents stated that they knew the advantages of
using it. The basic sources of trusted information were revealed as: Medical personnel
44
(76%) and TV (42%), while the educational channels were identified as: TV (76%),
medical personnel (48%), schools (39%) and newspapers (34%). Of the respondents,
98% had at least once bought iodized salt and only 3% of households were found still
using non-iodized salt in the 4th Quarter of 2003. The results of the effectiveness test
was used to roll-out a comprehensive national campaign during 2003 – 2004, with a
second reinforcement stage that continued into 2006.
116. As part of the communications campaign in Uzbekistan, a large-scale salt testing
operation was conducted during the fall of 2003 by grade 5-11 pupils. The testing of
almost 6 million household salt samples at 10,000 schools, coordinated between the
JFPR project, UNICEF and the Ministries of Health and Education, was accompanied by
lessons about the dangers of IDD and the benefits of using iodized salt. The overall
effort raised the awareness among teachers, pupils and families, was covered in the
major media and attracted wide public attention. The plan for the future included a next
School-based Salt Test Operation in 2004, along with the organization of a National IDD
Day in which school children would again play a major role. A UNICEF report mentioned
that of the almost 6 million samples tested, 56% were positive for the presence of iodate.
117. The rapid test kit for testing salt for the presence of iodate found effective
application in the Kyrgyz Republic also. The Kyrgyz-Swiss Health Reform Support
project in collaboration with MoH, JFPR and UNICEF organized several rounds of
community-managed test rounds of household salt sold in the wholesale and retail
markets of Naryn Oblast between mid 2002 and end 2003. In one round, the salt tests
were conducted by 65% of households, with the effect that in a period of 6 months,
iodized salt supplies to the area increased from 87% to 97%. In another round, the
repeated testing by village health volunteers of salt present in the households raised the
percentage of households using iodized salt from 71% to 90% in 5-7 months. In yet
another study, the testing of retail salt by community volunteers and retailers at
wholesale markets improved the household use of iodized salt from 65% to 76%. In all
areas combined, more than 90% of households were found using iodized salt by the end
of the 18 month period. The overall effort was estimated to cost around US$1,500.
118. In Mongolia, the communications strategy development was focused on three
directions, namely: Policy advocacy, insertion in ongoing educational systems, and
public education through established associations and unions of women, children and
consumer rights groups. Unlike the other JFPR countries, no participants from Mongolia
had attended at the follow up workshop on communication strategy design for IDD that
was sponsored by UNICEF in Astana in July 2002, but a mission of KAN
communications experts in 2003 assisted in diversifying and consolidating the work plan.
The communications activity package achieved particular visibility during an “All UN
Heads of Missions” meeting in May 2004 where the ADB-Mongolia social sectors officer,
upon CPO briefing, presented the JFPR-supported efforts in addressing micronutrient
deficiencies in Mongolia in the presence of Assistant UN Secretary General Dr. Kul
Gautam, who is UNICEF Deputy Executive Director and a tireless advocate on IDD and
anemia prevention. The briefing was held as highlight event of the national Summit for
Children. A particular challenge for the communications efforts in Mongolia is the
vastness of the territory. To overcome distance and still work effectively, the CPO
worked closely with the Mongolian Women Federation, the Consumer Rights Protection
Association and the National Board for Children in cascade trainings and the use of
distance education methods that permitted the message to reach into all distant districts
of the vast territory of Mongolia.
45
119. The experience in Tajikistan, as in Kazakhstan, Kyrgyz Republic and Mongolia,
confirmed the crucial importance of involving NGOs in the communication campaigns
due to their trust relationships and close connections into communities. By mid 2003, it
was estimated that more than 300,000 persons—many of whom were youth- were, or
had been, participating as volunteers in the communications campaign at city, district,
raion (Djaomat) and neighborhood (Makhallaya) levels through involving a broad range
of NGOs. The NGO actions when ongoing at these diverse levels were strengthened by
the simultaneous broadcasting of national and regional radio and TV programs featuring
national leaders, including the Minister of Health at several occasions.
2. Support for iodized salt production and quality measurement
120. The deliveries of internationally procured salt iodization equipment ran into
delays in the course of 2003 due to the shipment restrictions in the Persian Gulf area
related to the military operations in Iraq. In addition, the threat of pandemic SARS and
an associated quarantine prohibited the timely travel to JFPR countries by personnel of
China Salt Import-Export, delaying the installation of packaging equipment at the
selected beneficiary salt enterprises. By mid 2003, however, all the support items (Table
7) procured through JFPR funding had arrived in the countries, facilitated by customs
clearance with CPO support. A summary of JFPR support for iodized salt production is
in the following table, encompassing a total cost of almost US$630,000.00.
121. The delivery and installation of JFPR inputs in the Kyrgyz Republic was used as
an opportunity for direct meetings of Salt Producers Association Board members with a
specialist Presidential Advisor on the challenges to reduce cross-border leakage of non-
iodized salt from Kazakhstan, resulting in strengthened import regulations and
procedures on the shipments of industrial and food-grade salt. In Uzbekistan the arrival
of inputs for increased iodized salt production was coordinated with the holding of
training workshops and additional communications activities for improving the quality of
supplies and the knowledge, behaviors and use of iodized salt in the population.
Table 7: JFPR9005 Support Items for Promoting Salt Iodization
Iodization Packaging
Beneficiary Potassium Packaging
Country Equipment Equipment
enterprises Iodate (MT) Supplies
(units) (units)
Azerbaijan 3 0.3 1 3 Salt bags
Kazakhstan 2 3.25 1 1 Film rolls
Kyrgyz Salt bags and
2
Republic 7 1 3 Film rolls
Mongolia 22 0.2 - 4 Salt bags
Tajikistan 3 1.15 2 2 Salt bags
Salt bags and
Uzbekistan 5
13 3.9 12 Film rolls
Total 50 9.80 19 17
122. Following upon the delivery of iodized salt production inputs, the RCAO
coordinated with CPO managers in organizing assistance for monitoring inputs by the
supplies of laboratory and food testing equipment as per specification (Table 8).
46
Table 8: JFPR9005 Support for Quality Assurance and Inspection of Salt Iodization
Laboratory and Diagnostic Equipment (units) Local
Procurement
Country Spetro- Salt WYD Salt Iodine of Reagents
photo- Iodine Iodine Rapid and
metres Titration Checkers Test Kits Supplies
Azerbaijan 2 5 10 2,000 n/a
Kazakhstan 2 4 2 7,000 $1,965
Kyrgyz Rep 2 5 50 14,000 $1,650
Mongolia - 10 11 -
Tajikistan 2 2 5 20,000
Uzbekistan 2 5 5 -
123. The same allocation of two spectrophotometers was made to each country,
except Mongolia where previous assistance of JICA had already provided this
equipment to the laboratories of the Public Health Institute and the new State
Specialized Inspection Agency. The spectrophotometer equipment donations were
intended to strengthen the laboratory capacity in the designated scientific as well as the
State agency laboratories for measurement of the vitamin and mineral content in fortified
flour or flour products.
124. The salt mini-laboratories and WYD checkers were intended for the analysis of
iodine content in salt. Recent studies in CDC Atlanta had confirmed that the
measurement results of the WYD checker were equivalent to the “gold standard” results
obtained by titration. The checkers are more robust and user-friendly, and therefore,
they were preferred for use in small side laboratories in salt industry. Although the rapid
test kits for salt iodine are not strictly diagnostic, their supply was included in the
requests. Their utility is mostly in the sphere of communications, as described above for
the Kyrgyz Republic and Uzbekistan, by a demonstration “on the spot” whether iodate is
present in a given salt sample. The list finally includes a small amount of locally
purchased reagents. The total expenditure for this supply effort (Table 8) was just above
$150,000 in total.
3. Preparations for a follow-on JFPR project
125. The delegations of principal stakeholders at the mini-Round Table in Bishkek in
April 2003 had noted the great variation in achievements between the participating
countries and the sizable remaining shortfalls in reaching the stated project objectives.
Some evidence was available that iodized salt supplies were on the increase in
Kazakhstan and Kyrgyzstan for example, but legislation and the associated iodized salt
control efforts and the social mobilization campaigns were lagging behind scheduled
plans, especially in Mongolia, Uzbekistan and Azerbaijan. The meeting came to a
general consensus that an extension was desired of the JFPR9005 project period to
allow more time for the plans to get realized. In the mean time, the project leadership
initiated discussions and started working on the preparation for a follow-up project that
would take the pilot nature of the JFPR9005 project to a comprehensive, full-scale
fortification effort in those countries where substantive progress was tangible at the end
of the JFPR9005 period.
47
4. Second Round of Sentinel Studies: May 2004–August 2004
126. The second round of the Sentinel Studies was carried out about 12 months after
the first round, just upon the introduction of large-scale production of fortified foods in the
participant countries. In May–August 2004, the 2nd round was carried out in the same
households as the first round. Biological measurements of iron, folic acid and iodine
status were added from women of reproductive age who were living in the same
households as the children. The results of the 2nd round Sentinel Studies, presented at
the Almaty Forum 2004, were indicative of the high variability of biological indicators in a
normal, free-living population, which is a usual finding of such surveys. At the same time,
however, the first evidence was collected that the acceleration in the supply of iodized
salt in JFPR countries had started to make a dent in the high proportion of children with
deficient iodine status. The median values of the iodine content in urine samples among
the children, which is an immediate reflection of their iodine intake, in Azerbaijan,
Kazakhstan, Kyrgyzstan and Uzbekistan showed strong improvements compared to the
baseline values one year ago. Although there was some improvement in Tajikistan at the
margin of the iodine distributions, the shift of iodine consumption as was so obvious in
the other countries had not yet taken place, and in the children in Mongolia, no change
in iodine consumption or status was yet apparent.
J. Iodized Salt Production: Mini Round Table in Bishkek, July 2004
127. By the spring of 2004 it had become evident that the major investments to
develop the capacities of salt enterprises had started bearing fruit in the participating
countries by sizable increases in iodized salt supplies, though individual performances
varied by company and country. A quick assessment during 2004 showed that in the
aggregate, more than 100% of the salt industries’ commitments for increased iodized
salt supplies had already been met. Also more than 75% of one-third of the costs of the
JFPR-provided KIO3 iodization fortificant had been reimbursed by the beneficiary
enterprises before April 2004. It would be timely, therefore, to assess and augment on
the salt companies’ political will and information access required for self-sustained
iodized salt production and supply.
128. The other related development that had started taking place was that the salt
companies increasingly recognized the usefulness of collaborating in the National
Steering Committees as a single entity of a national Salt Producers Association. The
joint sector approach was particularly visible in the Kyrgyz Republic where the new and
established salt enterprises had become ever more assertive in shielding their markets
against unfair competition from outside. Also in Uzbekistan, a Producers Association had
been formed mainly in a Government-led attempt to strengthen the sector and stimulate
the quality and amount of national iodized salt supplies.
48
Table 9: Salt Iodization Status in JFPR Countries, Spring 2004
National iodized salt supply (MT) Reimbursement of KIO3 costs (US$)
Commitment Commitment
(66% of the Cumulative (33% of the Cumulative
Estimated Amount up KIO3 Supply Amount up Percent
Country Consumption) to Q1 2004 Percent Costs) to Q1 2004
Azerbaijan 21,120 8,566 41 1,485 0 0
Kazakhstan 39,600 78,253 198 17,355 17,355 100
Kyrgyz Rep 13,200 13,630 103 4,996 3,997 80
Mongolia 6,100 5,243 86 1,023 384 38
Tajikistan* 16,900 47,551 281
Uzbekistan 66,530 55,616 84 18,112 11,458 66
Total 163,450 208,858** 128 42,970 33,194 77
* The salt companies of Tajikistan were exempted from costs reimbursement
** Prorated over 2003, the realized total production of iodized salt in JFPR countries was 168,800 MT, or
81%
of the estimated national consumption needs.
129. In Bishkek, Kyrgyz Republic, on 12–13 July 2004, JFPR supported the
Association of Salt Producers of the Kyrgyz Republic, together with UNICEF and KAN, in
organizing a Regional Workshop of Salt Producers of Central Asia. The workshop aimed
to stimulate self-sustainable production and input procurement in salt enterprises and
was organized around a plenary part for presenting and discussing the developments in
iodized salt production and supply to the populations, and a self-directed promotional
“Expo” part that afforded external companies of iodization and packaging equipment,
fortificant and other input materials to showcase their products.
130. Notably, a representative of the European Salt Producers Association, Eu Salt,
was present to outline the mandate, structure and activities of the organized salt industry
in Europe. Also representatives of China Salt Company and Lonestar Corporation, who
had been selected in the competitive bidding participated actively in the exposition and
the proceedings of the workshop. The recommendations adopted by the salt producers’
workshop (Appendix 4) give testimony of acceptance by salt industry leaders of the joint
collaborative approach to address the shortfall of dietary iodine in the population and
their political will to continue collaborating with like-minded organizations through the
exchange of information and experience, and improvements in national and regional
facilitation mechanisms.
K. Completion of JFPR9005 and initiation of JFPR9052
131. Also in July 2004, under the JFPR, ADB approved the proposal for a follow-on
regional project for Sustainable Food Fortification in Kazakhstan, Kyrgyz Republic,
Mongolia, Tajikistan and Uzbekistan. This new project, which became known as
JFPR9052, was being scheduled for the 25-month period beginning in May 2005. While
JFPR9005 supported the initiation and piloting of actions to reduce the high prevalence
of IDA and IDD among the poor, the JFPR9052 goal was to reinforce and sustain these
reductions by parallel support and attention to establish ongoing systems in the supply
and access of fortified food products, while assuring food quality based on established
regulations.
132. The new goal statement had important consequences on how the renewed
collaboration became positioned during the follow-up phase. The JFPR9052 objectives
included a target of at least 90% of the salt consumed in households; they also included
a target for the domestic consumption of fortified wheat flour. This made it necessary to
49
elevate the focus in the next years in each country from only the areas with high
populations of poor people to a truly national endeavor. The second important shift in
paradigm in JFPR9052 was that emphasis was on activities that improve the
sustainability of the supplies and consumption. It was envisaged that the major part in
this second shift would be achieved by ensuring that the salt and flour producers are
self-reliant in their regular purchase of fortificant and other material inputs required for
fortification. The other part of the paradigm shift was projected to be achieved through
actions to promote integration and adoption of universal trade agreements, in the cross-
border transactions between the producers and their clients.
133. Compared to its predecessor, the JFPR9052 project did no longer include
support for Azerbaijan, in view of the wanting high-level Government will to ensure
effective operations and the delays in progressing on USI legislation. Also, the
Government of Uzbekistan had entered into an agreement with the Global Alliance for
Improved Nutrition (GAIN) for a major grant to promote fortification of wheat flour. The
JFPR9052 component focused therefore exclusively on improvements in salt iodization
in Uzbekistan.
L. Stocktaking in preparation for the Almaty Forum 2004
134. Since the Almaty Forum in October 2001, in continued collaboration with
UNICEF and other organizations in participant countries, the Asian Development Bank
through the JFPR9005 project delivered high-level advocacy, focused technical support
and substantial funding for food fortification, piloted capacity building of national and
regional marketing and sales networks, and demonstrated that a regional approach is
efficacious in accelerated efforts to address the micronutrient malnutrition problems that
disproportionately affect the poor.
135. In the 15-month period between January 2003 and March 2004 alone, JFPR9005
reported 81% realization of the 66% target production of iodized salt on basis of
producer self-reporting. The increased iodized salt supplies were sufficient to supply in
theory 33.5 million people, or 53% of the total population in the participant countries, with
additional iodine consumption. The project outputs helped protecting 600,000 newborns
from the brain damage of iodine deficiency that might have occurred otherwise. A
feature worth emphasizing is that the salt companies returned 77% of the fortificant cost,
or US$33 thousand, to the JFPR9005 management for further investment. These results
were testimony of the outstanding progress toward USI that was being made in Central
Asia and Mongolia during the 3.5 years of JFPR9005. The increased collaboration by
public-private-civic partnership and the continued blending of many different talents,
support resources, advocacy, technical assistance and investments by all supportive
groups had contributed in a significant way toward positioning the participating countries
for success in their pursuit of the agreed-upon goal of sustained IDD elimination through
USI.
136. What evidence was available of increased iodine consumption in the population
of JFPR countries during the project? In global practice, the share of the households that
are using iodized salt is the most frequent indicator of progress made toward USI. Using
this indicator has great advantages. The data can be obtained without special training as
part of other household surveys, the measurement checks on an answer to the problem
rather than the problem itself, and it focuses the attention on the location where humans
are affected. Nevertheless, the weaknesses of this indicator must also be understood:
Household salt is only one portion of the food-grade salt supplies to be iodized under
50
national USI policy, and the presence of iodized salt in a household does not necessarily
confirm that it is always used by all members in their daily diet. Notwithstanding these
drawbacks, the presence in households of iodized salt is most often the best available
evidence in a given country and these data are consolidated by UNICEF in a global
database which is regularly updated.
Table 10: Comparison of Iodization Status and Brain Protection Estimates, 2000
and 2004
Population in
a
millions Annual births in thousands
Household
Protected Salt %iodized per 1,000 total number number
Total against ID Value Year population number protected unprotected
JFPR9005 countries, end 2000 situation
Azerbaijan 7.7 3.3 43 2000 15 115 49 65
Kazakhstan 14.9 4.3 29 1999 14 207 60 147
Kyrgyz Republic 4.9 1.3 27.2 1997 22 109 30 79
Mongolia 2.5 1.1 45 1998 20 51 23 28
Tajikistan 6.4 1.3 20.2 2000 21 134 27 107
Uzbekistan 24.8 4.7 19 2000 23 570 108 462
61.1 16.1 26 1,186 297 889
Data sources: ADB Salt Situation Assessments; UNICEF 75%
JFPR9005 countries, 2004 situation
Azerbaijan** 8.2 5.7 70 2004 14 115 80 34
Kazakhstan** 15.4 12.8 83 2004 17 262 218 44
Kyrgyz Republic* 5.1 3.0 59 2003 21 108 64 44
Mongolia* 2.6 1.9 75 2004 23 60 45 15
Tajikistan* 6.2 1.7 28 2003 31 194 54 139
Uzbekistan* 26.1 14.6 56 2003 23 600 335 265
63.7 39.9 63 1,338 796 542
Data sources: * Beijing Conference; ** UNICEF 41%
a
Population sizes and crude birth rates from the UN Population Reference Bureau publication for the respective years.
137. Using the UNICEF database, the user shares of adequately iodized salt in the
JFPR9005 countries increased from 26% to 63% of the population between 2000 and
2004 (Table 10). It should be noted that the estimates for Uzbekistan and Tajikistan
were based on information of 2003, and therefore were likely underestimates of the true
situation by the date of JFPR9005 completion in August 2004. These salt iodization user
estimates indicate that almost 24 million new consumers of iodized salt were added in
the population of Central Asia and Mongolia during the first JFPR project, and an
additional 500 thousand newborns protected against brain damage of iodine deficiency.
138. Estimating the economic costs avoided by the correction of iodine deficiency is
somewhat uncertain, but a simple scenario calculation using the PROFILES worksheets
suggests that the savings to the national economies may have totaled as high as
US$150-225 million.
139. By using the proportions of households with adequately iodized salt in
combination with the birth rate in a country, estimates can be obtained of the number of
newborns each year that are delivered by mothers from households that consumed
51
adequate iodine in their common diets. By implication, it is expected that these mothers
“protected” their newborns against the risk of brain damage due to iodine deficiency.
Noteworthy, the crude birth rate in Tajikistan showed a major increase in the aftermath
of civil war, leading to sizable increases in the number of newborns. The Figure below
illustrates the reductions in the number of newborns yet to be protected in JFPR
countries (except Tajikistan, where the birth rate increased tremendously in the
aftermath of civil war). A further increase of the protection among newborns would be an
underlying challenge in the follow-on JFPR9052 project period.
Figure 7: Number of Newborns per annum yet to be Protected against Brain
Damage from Iodine Deficiency in the JFPR Countries of Central Asia and
Mongolia, 2004
IV. THE ALMATY FORUM 2004
140. The 2nd Almaty Forum was held 1-3 September 2004 at the same venue, almost
3 years after the 1st Almaty Forum. As was the case in 2001, the Almaty Forum 2004
assembled high-level national multi-sector delegations, composed of the public, private,
scientific and civic sectors of society, with the interrelated aims to review past progress
and discuss the details of the JFPR9052 agreements for progressing in the efforts to
reduce the burden of micronutrient deficiencies by fortification. Many delegates at the
Forum were member of national Steering Committees, which enabled sharing of past
experiences and facilitated further detailed development of CIPs. The Almaty Forum
2004 was also another example of the collaborative spirit among the JFPR managers in
headquarters, the regional office and the country offices with the networks of UNICEF
officers in the region and participating countries, as well as the KAN experts and the
international consultants. The primary onus during the presentations, discussions and
52
formulation of an Almaty Forum 2004 statement remained with the national delegations,
however.
141. The proceedings of the Almaty Forum in 2004 provided many examples of
accomplishments of the past period, in combination with tangible eagerness to reach for
more results during the time ahead. The presentations attested to the improvements in
collaboration that had taken place in the majority of the countries across the boundaries
between sectors, and the established realization that the nutrition challenges of
micronutrients required solutions that are based in the food supply situation. The
unquestioned focus on the ways and means to pursue sustainable fortification of salt
and flour was a confirmation of the broad acceptance that the key role and responsibility
for further progress needed to be sought in improving the performance of the salt and
flour productive industries.
142. To further assist in detailed development of the CIPs for the new JFPR9052
period, side-sessions were arranged of the CPO teams with KAN experts and
international consultants. The other way in which CPOs and their Steering Committee
members were assisted was by “issues papers” which had been prepared for this
occasion by the external consultants on the subject areas of Communications, Flour
Fortification, Salt Iodization, and Micronutrient Status. Each issues paper offered an
external expert view of the accomplishments during the past 3-year JFPR9005 period;
they highlighted the major lessons learned, and they gave a preview of the major tasks
that should be given priority in the new project period to achieve the ambitious goal of
sustainable production of quality fortified foods.
A. Short outline of the JFPR9052 project
143. Departing from the outcomes of JFPR9005 that convinced the Governments and
the private salt industries in Central Asia and Mongolia of the achievability of USI, the
goal of the JFPR9052 project became to reinforce and sustain the elimination of IDD
through giving parallel attention to supply (production and distribution); demand (public
awareness and demand creation); and regulation (quality control, implementation of
regulations and legislation, and trade facilitation).
144. Specific to USI, the objectives were
(i) Obtain and sustain the use of iodized salt by 90% of households,
(ii) Build the capacity of the private and public sectors to produce quality iodized salt,
(iii) Develop regulatory institutions or incentive schemes to facilitate iodization and
ensure the trade of quality iodized salt among participant countries, and
(iv) Build awareness among consumers about prevention of IDD and benefits of
iodized salt.
145. In contrast to the pilot nature of the previous JFPR9005 period, JFPR9052 set
out to build national capacities to sustain USI. Thus, the project worked with the private
sector and Government agencies nationwide rather than in pilot areas. An important
tactic of JFPR9052 was to assist salt enterprises in accessing information and procuring
iodization inputs by themselves: The project set out to give support to fortificant and
equipment procurements by facilitating linkages with global supply sources. At the same
time, the project would work to strengthen and improve the quality assurance systems of
the public agencies as well as the private producers to ensure that consumers receive
iodized salt that meets agreed-upon quality standards, and it would help consumers
53
ascertain the quality of iodized salt. The JFPR9052 project had a total budget of
US$4.88million, of which the JFPR provided US$2million. Governments of the
participating countries were to contribute US$0.34million and the projected inputs by salt
manufacturing and flour milling industries was US$2.55million.
146. Using mechanisms developed during the previous period, shared activities in the
JFPR9052 project included the tracking of outcomes and impact, regional exchange of
technical information, and multi-country capacity development and sharing of lessons
learned, inter alia through the Caffproject website. As before, the role of international
consultants remained focused only on critical tasks, related to major goals. Monitoring of
outcomes and website maintenance was delegated to KAN. Finally, the management in
participating countries remained through CPOs, in close interaction with the established
Steering Committees. The Ministry of Health in each country was Executing Agency,
implementing the project in close coordination with partner Ministries, private salt
producers and milling industries, NGOs and community-based organizations. The
JFPR9052 project commenced formally in May 2005 for a 25-month period and in the
interim period, ADB renewed its letters of agreement with the countries and the CPO
teams arranged for revisions of the letters of agreement with participating industries.
B. Progress in implementing JFPR9052
147. Compared to the predecessor project, the action in the JFPR9052 period to
reach the USI goal was focused principally on the acceleration of in-country execution.
Region-wide sharing continued as part of two commodity-specific workshops on quality
improvements in salt iodization (Tashkent, November 2005) and stimulation of flour
fortification (Almaty, February 2006), and a mid-term review workshop (Cholpon Ata,
September 2006). In addition, quarterly progress reports by RCAO and several CPOs
helped in stimulating regular exchanges of information, as did a number of country
newsletters and the periodic updates on the Caff-project website. The 3rd round of
Sentinel Studies coordinated by KAN were conducted during the 2nd and 3rd quarters if
2007, i.e. 3 years after the 2nd round, which facilitated the capture of nutritional impacts
from both the supplies of iodized salt as well as fortified flour in the pilot focus areas and
households of the study.
C. Sustainable Quality Salt Iodization: Mini Round Table in Tashkent,
November 2005
148. In Tashkent, Uzbekistan, 22-24 November 2005, JFPR9052 sponsored the 2nd
Regional Conference of Salt Producers of Central Asia and Mongolia. The meeting
brought together salt industry leaders—assembled in Salt Producers Associations of
Kazakhstan, Kyrgyzstan, Mongolia and Tajikistan—with the key stakeholders of all JFPR
countries to discuss the policies and practices required to achieve and sustain quality
iodization of the edible salt supplies in the region. Following the overall trust of the
JFPR9052 project, the Conference proceedings stressed the issue of quality assurance
of the salt supplies as a joint task for producers and officials, thus emphasizing the roles
and responsibilities of the partners while starting out at production. The main objectives
were to improve the capacity of the salt industries; provide the salt, fortificant, and
equipment firms an opportunity to showcase their products, knowledge and services;
establish and strengthen the interactions of the salt producers with reputed international
suppliers of fortificant and equipment; and consider the enforcement routines for
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reassurance that the iodized salt supplies remain in conformance with agreed-upon
standards.
149. The agenda included a series of presentations of the modern insights about the
various aspects of quality salt iodization from the viewpoints of the producers and
traders, fortificant and equipment suppliers, and authorities tasked with food quality
control. The salt producers associations and leading salt companies shared their
experiences from practice in quality iodized salt production, and presented their visions
of their needs in sustaining the quality of their food-grade salt supplies. The various
speakers stressed the significance of the enactment of a principle national law for
reaching mandatory USI—a detail that was not lost on the hosting government of
Uzbekistan. International suppliers of salt iodization equipment (SERRA, Spain), rapid
test kits (MBI, India), and potassium iodate (Ajay-SQM, Chile; L-Pharma, Kazakhstan
and Iodobrom, Ukraine) offered consultations and presented an interactive exhibition to
the attending country groups and associations.
150. The meeting produced a consensus statement (Appendix 6) on the principle
actions for establishing effective policies at national and regional levels to maximize
access by poor families to quality iodized salt. The consensus statement emphasized
two basic principles, namely that (a) achieving USI is a key role and responsibility of the
salt production companies, and (b) establishing vibrant salt producer associations is the
critical mechanism for successful collaborative partnerships in each country to reach the
objectives of universal quality iodized salt supplies and increased cross-border trade.
D. Mid-Term JFPR9052 Project Review, Cholpon Ata, September 2006
151. The JFPR9052 Mid-Term Review Workshop was conducted from 11 to 14
September 2006 in Cholpon-Ata, Kyrgyzstan. The purpose was to jointly examine the
progress and analyze the obstacles toward achieving the JFPR9052 project’s objectives,
with a view to identify and discuss key strategic actions for each country, RCAO and
KAN during the remaining project period. In preparation of the Workshop, the CPO of
each country prepared a draft amended CIP, with a summary of lessons learned during
the previous JFPR9052 period and proposed actions and their expected outcomes for
the upcoming 12–16 month period. In addition, the CPOs had prepared a quantitative
summary of the progress in salt iodization, wheat flour fortification and public policy
development, as well as the utilization of consultant services and the conduct of
conferences, seminars and trainings, against a background summary of the baseline
situation in each country. The workshop brought together officials and staff from public
institutions and private food industries of each participating country, RCAO, international
agencies and a collaborating partners (UNICEF and GAIN) and scientific advisors (KAN,
Emory University), 40 persons in total.
152. The conduct of the meeting was fully participatory. The core elements in the
agenda were country presentations, each consisting of a condensed summary of
progress made during the past period, followed by analysis of the constraints
encountered and the barriers foreseen for the remaining period, and ending with a short
outline of the major revisions of the CIP. The presentations were followed by a
discussion to provide clarification of details upon request from the audience. The country
presentations were intermingled with plenary presentations and round table discussions
around the issues of major interest, such as detailed methods for product quality
assurance and control, practices in monitoring of progress in project implementation,
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and communication actions in support of the overall project objectives. The facilitators
and resource persons worked in the interim and during the evening hours with the
country teams on the detailed elaboration of CIP revisions. During the final day, bilateral
discussion sessions were held to present, discuss and review the CIP revisions, and to
assemble the consolidated opinions and recommendations of the resource persons for
near-term actions.
153. On quality salt iodization, a summary of the progress made, the issues discussed
and the plans for the remaining project period follows:
154. Preliminary results of the MICS survey in Kazakhstan conducted by the Kazakh
State Statistics Agency in early 2006 suggested that more than 90% of households were
using adequately iodized salt, indicating that Kazakhstan may be the first participating
country to reach the JFPR9052 goal. Employing the same sampling framework as the
MICS, KAN conducted a quantitative survey of the iodine nutrition status in the
population during March-May 2006 with women of child-bearing age as the population
index group. The results of this survey were being analyzed. During the remaining
period, the CIP would be paying attention to a few specific remaining imperfections in
ensuring the quality of the edible salt supplies from PavlodarTuz and foreign sources
(mainly from Russia), and complete the legal and normative framework that supports
sustainable quality USI. Anticipating on the demonstration from the recent USI/IDD
survey that the iodine nutrition situation is optimal, the project would aim to promote
collaborative work with UNICEF and KAN to devise a USI/IDD surveillance system for
the early detection and follow-up of failures in iodized salt markets related to the
respective supply sources.
155. In Kyrgyzstan, the Kyrgyz Association of Salt Producers (KASP) has played an
increasingly activist role in efforts to address the imperfections in the iodized salt
supplies. The first order of attention was to address the leakage of non-iodized salt into
the Kyrgyz markets from Kazakhstan, which in 2001 affected about one-third of the salt
consumed in the households. Working with JFPR and other partners, KASP pressed for
improved border control on the trade in raw salt harvested from deposits in Zhambyl
Oblast of Kazakhstan, and it supported the use of information from the market raids in
Kyrgyzstan to expose the illegal sale of non-iodized salt. The success of this approach
had become evident from a significant reduction in the share of non-iodized salt in the
households: Comparisons of the MICS surveys in 2001 and 2005 showed that the use of
non-iodized salt in the household had fallen from 35% to less than 5%. During the early
JFPR9052 period, KASP worked with JFPR, the Kyrgyz-Swiss Health project, the ADB
project on Early Child Development, UNICEF and local health authorities to extend the
market raids, which had started in Naryn Oblast in 2002, to an increasing number of
Raions and Oblasts. In these raids, Family Group Practitioners organized salt tests in
the households, while SES officials and local authorities were testing the salt for sale in
the markets and shops. Retailers used the test kits to ascertain that their suppliers were
providing iodized salt and KASP was following up to correct improper practices in
iodized salt production.
156. In Cholpon Ata, the Kyrgyz group presented a plan to publicize the names of salt
companies found to be selling non-iodized salt in the local and national media. The
recent MICS findings in Kyrgyz Republic indicated that priority for the remaining
JFPR9052 period should be on reducing the remaining low quality iodized salt in at least
20% of the supply. The plan, therefore, was to address the weak quality assurance
56
practices of some domestic salt manufacturers and the lack of insistence by key food
processing industries on using iodized salt. KASP would be supported to extend its
memberships to all viable salt producers and, in collaboration with UNICEF and the
Kyrgyz-Swiss Health Reform Project, to continue raids in the markets of selected Raions
in the country (with special focus on poor areas), followed by publicity on salt brands
found to infringe on the mandated salt iodine levels. The project would also encourage
KASP to establish a buffer stock of guarantee-priced potassium iodate, based on a
scheme of prepaid claims by the salt industries.
157. Although it had long been apparent that the goal of >90% iodized salt
consumption in Mongolia was not attainable without serious attention to making sure that
all the salt imported from China for the most populous central area of Mongolia is
iodized, the efforts during the early JFPR9052 period remained directed mostly toward
increasing the supplies and quality of locally produced iodized salt. For the remaining
period, the team agreed to CIP action to make sure that the edible salt imported from
China, estimated at up to 90% of the domestic needs, is adequate quality iodized, by
assisting customs authorities and commercial importers in procurement procedures with
specified purchase orders and control arrangements that can be sustained after project
finalization. In Western Mongolia—among the poor and far-flung rural areas in the
country-, the plan remained to continue assisting small enterprises in quality assurance
practices to complement the previous training and equipping. The project would also
hold targeted advocacy and trainings with authorities and local NGOs (social grants and
contracts) to build community-based pressure to insist on only iodized salt supplies in
the food markets and thus promote exclusive market access to quality iodized salt.
158. In Tajikistan, the results of the MICS 2005 had demonstrated that 40% of
households in Kathlon Oblast and 57% of households in RRS were still using non-
iodized salt. The salt deposits in Kathlon Oblast were a major source for the slow
progress in achieving the national USI goal. The partners had collaborated during the
early JFPR9052 period in organizing the more than 80 salt producers in Kathlon Oblast
into 7 small producer cooperatives, intended to enter into contractual arrangements with
the Khuja Mumin salt factory to deliver their production at an agreed-upon fixed price,
while the Khuja Mumin factory committed its capacity for the iodization of the salt from
the cooperatives. The salt is packed in standard 2kg bags, with Healthy Food logo and
marketed at a price that is not different from non-iodized salt. The project worked also
with the SES authorities in GBAO, RRS and Kathlon Oblasts to strengthen the quality
control and food inspections at production. SES started conducting salt tests at road
checkpoints on the main trunk roads leading from the Kathlon salt deposits to the major
consumer markets in these Oblasts. Added to the major existing iodized salt capacity, 2
new salt factories capable of iodization were established in Kathlon Oblast during the
first phase of JFPR9052, namely AO Dushanbe and LLC Dilovar. Both factories self-
procured equipment for iodization and packaging during the past year. For the remaining
period, the CIP planned further facilitation of the cooperatives in Kathlon to ensure that
the edible salt produced by small-scale enterprises will be quality iodized. The project
would further support inspections by SES and/or local authorities at road blocks of salt
transport from these cooperatives to the consumer markets in Kathlon and RSS Oblasts.
Further, the project would assist in establishing agreements on reduced or abolished
VAT on potassium iodate imports and on iodization equipment.
159. In Uzbekistan, the draft law on IDD elimination, developed during JFPR9005, had
passed a first round of reviews in Parliament during the past JFPR9052 period. The
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MICS results had shown that in spring 2006, slightly above half of all the households in
Uzbekistan were using quality iodized salt, a similar result as 2-3 years ago. Anticipating
upon the enactment of the USI law in the nearby future, the CIP revision for the next
period was to follow through by supporting a more vibrant National Salt Manufacturers
Association (NSMA), by promoting sustained coordination. The CIP included also
specific support to NSMA for building its memberships and strengthening the capacity to
assist its members by training technicians in practical methods for quality assurance of
iodized salt during production. The CIP provided for a temporary salt industry expert to
strengthen the focus of NSMA’s agenda and actions on solving key important technical
salt iodization issues for the salt industry in Uzbekistan. In view of usual price
fluctuations in the world market, the CPO set out to collaborate with NSMA in a review of
the KIO3 procurement with the aim to devise a sustainable arrangement of fortificant
access by the salt producers. The CIP also included advocacy for subsidiary decrees or
acts that reduce government taxes on KIO3 and/or salt iodization input procurements. To
increase awareness and consumption, actions with Customs would be promoted on
quality control of imported salt and with SES or NGOs on rapid testing of salt brands
offered for sale in poor communities, followed by exposure and publicity of non-
compliant salt. To promote sustained awareness, the project planned an extension of the
previous work with the Ministry of Education to insert the essential knowledge of IDD
and the mandate for USI in colleges, high schools and other relevant educational
curriculums, including health care professionals.
160. In summary, the mid-term review in Cholpon Ata provided each country team
with an action plan aimed at progressing toward the JFPR9052 goal of >90%
consumption of quality iodized salt in the population. The following sections capture the
major developments in promoting quality salt iodization in the participating countries.
Each section pays attention to the particular JFPR9052 approach of parallel support and
attention to supply, demand and regulation, while the overall achievements will be
summarized in a final section.
E. Kazakhstan
1. Supply
161. In terms of the national supplies, the salt market in Kazakhstan has traditionally
been dominated by the veteran enterprise AralTuz (see Salt Situation Analyses 2001-
2002, page 23) in Kyzl Orda Oblast near the Aral Sea. The supply of iodized salt by
AralTuz for the domestic market increased during 2000-2006 from approx. 35,000 to
57,000MT according to official reports of the Agency of Statistics. In 2005, Araltuz
invested in five modern automatic packing machines, made in Russia and valued at 17.2
million Tenge. This increased the productivity of the processing line, improved the
durability and tightness of the seams of the 1kg packages and added modern photo-
labeling on the packages with an automatic imprint of the manufacturing date. Also a
new pump for the iodization spray unit was purchased by AralTuz in 2005 for 3,300 US$.
The 2nd important salt producer in Kazakhstan, PavlodarTuz, is located in Pavlodar City
in the north-east of Kazakhstan. Official statistics show that the supply of iodized salt by
PavlodarTuz remained at approx. 3,500MT per annum throughout the JFPR9052 period,
or less than 5 percent of the domestic per capita salt consumption estimate. In the
period up to 2006 while AralTuz was expanding its iodized salt production, PavlodarTuz
remained lukewarm to the national élan to reach USI, mostly due to rapid changes in
management. During a visit to the Solyetska salt lake production facility of PavlodarTuz
in June 2007, the data entries in the laboratory journal made apparent that the quality of
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the iodization step had improved markedly from previous levels that fluctuated around
25mg/kg into September 2006, toward a narrow range around 40mg/kg by the end of
2006. The improvement coincided with the relocation of the company’s QA laboratory
from its administrative office in Pavlodar City to the production facility in Solyetska, thus
promoting an immediate feedback of the laboratory results to the production line
manager.
162. During 2005, a new salt production enterprise located in South-Kazakhstan
Oblast, SuzakTuz, entered the domestic market for consumer salt with an estimated sale
of up to 5,000MT. The factory is located in the small township of Suzak, South-
Kazakhstan Oblast at 150-200 km north-northeast of Shymkent, the Oblast capital. The
company harvests salt from a natural salt lake located at more than 100 km from the
processing factory in Suzak township. The continuous processing line consists of dry
milling, an electrical furnace and a drip iodization unit followed by a screw conveyor and
bagging station for 1kg hand-sealed packs. In June 2007, the company had ordered -but
not yet received- iodization spraying and titration equipment for iodine measurements. A
laboratory room had been prepared already with a mounted electrical water distillation
unit and work benches. It is likely that the salt sales of SuzakTuz in 2006-2007 did not
travel far beyond the borders of the nearby Oblasts, namely Kyzyl Orda, Zhambyl and
possibly Almaty Oblast and City.
163. For the year 2005, the import of iodized salt into Kazakhstan was reported as
7,000MT from Russia, 8,400MT from Ukraine and 300MT from Belarus, on top of the
domestic production of 66,500MT. Imported iodized salt therefore made up
approximately one-fifth of the domestic consumption. The export during 2005 of iodized
salt manufactured in Kazakhstan was less than 3,000MT. The domestic supply source of
the potassium iodate (KIO3) fortificant in Kazakhstan is “L-Pharma” company in Almaty
which sources it from a chemical company Troitskii ChimZavod based in Uralsk, Russian
Federation. Portions of 0.5, 1 and 3 kg KIO3 are packed in a double layer lightproof film,
wrapped up in paper and boxed in units of 30 kg. The stated expiry period for storage is
3 years. The cost to salt producers of 1 kg of KIO3 was 4,300 Tenge or 35.00 US$
including taxes. In 2005, L-Pharma import firm sold 4,140 kg KIO3 and in 2006, 3,420 kg
to the salt producers in Kazakhstan.
164. The active collaboration by the domestic salt companies –especially AralTuz- in
the national IDD elimination program, in combination with the communications support
work, equipment provision and the training of the laboratory technicians and managers
in the enterprises have had a great influence on the increases of the amount and quality
of iodized salt production. The main goals of the Association of Salt Producers in
Kazakhstan, established in September 2005, include the coordination of joint actions
aimed at promotion of Kazakh’s salt products for internal and foreign sales markets,
protection against adulterated products including imported products, improvements in
production of quality iodized salt, improvement of process technologies, and solution of
other corporate issues. The Association’s members include AralTuz, SuzakTuz, Salt
Trade Company, Salt Industries and Tuz, but not PavlodarTuz. The head office of the
Association is located in Almaty. The Association of Salt Producers in Kazakhstan was
provided with semi quantitative spot-tests, informative communication materials, and
materials on use of “Healthy food” trademark which has been shared with their member
network.
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2. Demand
165. The successful initiation of IDD awareness campaigns in Kazakhstan was
described in detail as part of the JFPR predecessor period. The important, but often
underexposed, tactic in these campaigns was that despite the ultimate targeting of the
campaigns at the end-consumer, the major opinion intermediaries of society were
involved in the delivery of the messages and information. Therefore, the campaigns
were not only raising the awareness and acceptance among the general public, they
also were instrumental in ensuring that mandatory salt iodization became accepted as
the regular, ongoing practice by the stakeholders of opinion in the society of Kazakhstan.
JFPR9052 continued working with the coalition of NGOs and local constituencies as well
as KAN in extending and widening the campaigns. A very broad array of
communications materials used in the campaigns benefited from contributions by the
food industry. The campaigns raised also the awareness among the public of the key
significance of the products carrying the Healthy Food logo.
166. Another important tactic in raising the acceptance and sustainability in
Kazakhstan was that, starting out from the JFPR9005 period, KAN has continued
working steadily to insert technical learning of IDD elimination through USI into the
curriculums of public secondary schools, technical expert training and continued
education programs. The materials developed by the KAN for medical staff were
approved by the Scientific Department under the Ministry of Health, and then distributed
all over the country to the policlinics of small towns, district, and rural medical units
through the Oblast health departments. The regional branches of the National Centre for
Healthy Lifestyle and the Centres for Health Strengthening trained the medical staff of
more than 1,000 points of primary medical and sanitary assistance in the country.
Education on preventive measures against iodine deficiency became included in the
regular training curriculum of primary health care personnel. As long-term and
permanent infusion into the healthcare system of the Republic of Kazakhstan, it is
necessary to use the training resources of the Almaty State Institute of Doctors’
Advancement under the Ministry of Health and the same faculties of doctors’
advancement under the Medical Academies and Universities; and also resources of the
Republican Medical College (Almaty city) and large oblast medical colleges to advance
the professional level of the middle medical staff of the country. Knowledge on IDD
prevention was inserted into these curriculums, and the pre- and post-degree
preparation courses of the aforementioned medical institutions. The methodical
materials for teachers of the state secondary schools developed by the KAN were
approved by the Republican Educational and Methodological Council of the Ministry of
Science and Education of the Republic of Kazakhstan and recommended as an
additional study material to be used in the course of natural science subjects at public
secondary schools. These teaching and methodological materials together with
laboratory sets for spot-tests were provided to all 8,200 state schools of Kazakhstan
through the Oblast education departments during 2005-2006.
3. Regulation
167. Universal salt iodization in Kazakhstan is mandated by the Decree of the
President № 489-PZ, dated 14 November 2003, “On Prevention of IDDs”:
• Article 11, on Requirements for Quality and Safety of Salt, states:
o Dietary and fodder salt produced on the territory of the Republic of
Kazakhstan is subject to mandatory iodization
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o It is prohibited to produce, import, and sell salt on the territory of the
Republic of Kazakhstan if iodization requirements established by the
Article are not compliant, and
o It is prohibited to produce, import and sell adulterated dietary salt.
• Article 14, on Requirements for Packing, Labeling and Storage of Iodized Salt
and other Foods Fortified with Iodine Compounds, specifies:
o The package of iodized salt and other foods fortified with iodine shall
contain the following information written in national and Russian
languages: nutritional and caloric value, content of iodine compound,
designation and conditions of use, and storage terms and conditions.
168. According to the Order of the Prime Minister № 64-P, dated 25 March 2005, On
Measures of Execution of the Law “On Technical Regulation”, there is a two-level
system of technical regulation of laws, namely (1) Obligatory regulatory legal acts
(technical regulations) accepted at the government level, and (2) voluntary standards
and other regulatory documents. As to obligatory acts, the Ministry of Industry and Trade
(either through The Committee for Technical Regulation and Metrology or the State
Committee for Standards and Metrology) has the authority on behalf of the State to
define requirements for products by setting product composition, safety and compliance
standards. For this purpose, 141 agencies to verify product compliance with
requirements and 394 testing laboratories have been accredited in Kazakhstan and
among these, 34 agencies and 40 testing laboratories deal with food products. The two
State Committees perform these activities in compliance with the Laws “On Technical
Regulation” dated 9 November 2004, and “On Provision of Uniform Measurements”
dated 7 June 2000.
169. As described before, the President of Kazakhstan has co-signed the Inter-State
Agreement of Minsk in May 2001, on joint collaboration in the Commonwealth of
Independent States in preventing iodine deficiencies. The interstate standard GOST
13830-97 on “Dietary Table Salt” has therefore been accepted as an obligatory act of
technical regulation for the universal iodization of food-grade salt. The Minsk document
provides for exclusive competence of public health authorities of each CIS country to
define the type of fortificant, the required iodine concentration in salt and the methods of
quality control of iodine content in salt. The production, quality and safety of foods,
dietary supplements and therapeutic products is governed by the regulatory document
SanPiN 4.01.071.03 and by technical standards for foods, approved by both the Ministry
of Health and the Ministry of Industry and Trade. Following the Minsk agreement, the
standard for iodized salt in Kazakhstan (ST RK GOST Р 51575-2003) has been set at
40±15 mg/kg which is congruent with recommendations of ICCIDD, UNICEF and WHO.
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Figure 8: Certificate of Conformity of iodized salt production
170. Prevention of IDD in Kazakhstan is not being pursued by the strategy of universal
salt iodization alone. A Presidential Decree № 1438 “On the State Program for Public
Health Services Reform and Development 2005-2010”, dated 13 September 2004, was
followed by an Order of the Ministry of Health № 637, dated 23 December 2005 on the
“List of Diseases and Categories of the Population, the outpatient treatment of which is
supported with free-of-charge medicines and specialized dietetic therapy that are
prescribed under favourable conditions”. This Order provides for the entitlement of
pregnant women and children under two years old to State-financed iodine supplements.
On 29 August 2006, the Ministry of Health also submitted for consideration to the
Government a project of proposed amendments to the Law “On Prevention of IDD”,
which envisages the permission of the use of non-iodized salt for manufacturing of
certain grades of rennet cheese and salted caviar of export value.
171. The Ministry of Health issued an Order № 641 “On Approval of Rules for
Monitoring of Quality, Production, Storage, Import and Sales of Iodized Salt and other
Foods Fortified with Iodine Compounds”, dated 18 August 2004, which commits the
agencies and authorities of SES to carry out regular sanitary-hygienic inspections of salt
quality at production, storage, import and sale of iodized salt, followed by quarterly
reports from the Oblast SES to the Republican Sanitary-Epidemiologic Station (RSES).
Every quarter, RSES must present the information from inspection results to the
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Committee of the State Sanitary-Epidemiologic Supervision under the Ministry of Health.
Execution of the Order is overseen by the Chief Health Inspector who is Chairman of the
Committee of State Sanitary-Epidemiologic Supervision under the Ministry of Health.
172. Control of import and trade in salt by commercial enterprises is the responsibility
of authorities of the Committee on Technical Regulation and Metrology of the Ministry of
Industry and Trade, and regulated by a mandatory Certification of Conformity (CoC)
(Figure 8). On 20 April 2005, the Ministry of Industry and Trade approved a list of
products that are subject to mandatory CoC, “food salt” being included in the list.
Obtaining a CoC depends on the QA competency inherent to the production enterprise.
If a company has obtained ISO or HASSP standards, a CoC is valid for 2-3 years. If an
enterprise has no such international standards, certification occurs for the output of each
batch of products. According to the 2007 budget plan of the Ministry of Industry and
Trade, 20 million Tenge were allocated for purchases of samples of products, including
food, and for independent assessment of the CoC, including iodized salt.
173. Oblast and District SES authorities collect data on the physical persons and legal
entities involved in production, storage, import and sales of food products according to
types and quantities of product. SES inspectors perform tests of the quality of food
products against standards as approved by Government. The results of these
investigations must be submitted each quarter to the Republican SES by the 20th day of
the last month. In turn, the Republican SES must submit the summarized data by
Oblasts of Kazakhstan to the Committee of the State Sanitary-Epidemiological
Supervision under the Ministry of Health by the 25th day of the last month. The MOH in
Astana consolidates the data across Kazakhstan obtained by SES in a regular
database. Table 11 shows the results of the quality inspections by SES of iodized salt in
Kazakhstan into 2007.
Table 11: Results of inspections of iodized salt by SES bodies in Kazakhstan,
2005–2007
Total amount of salt Content of iodine in Percentage adequately
samples salt 40±15ppm iodized salt
2005 9,839 9,544 97%
2006 11,093 10,837 98%
Ι quarter 1,854 1,817 98%
ΙΙ quarter 2,461 2,395 97%
ΙΙΙ quarter 3,366 3,299 98%
ΙV quarter 3,412 3,356 98%
2007
Ι quarter 2,331 2,286 98%
174. The arbitration of disputes with enterprises about the results of inspection is
assisted by laboratory counter-measurements in the National Iodine Laboratory at the
KAN.
175. Since 2006, the 245 territorial SES inspectors (National, Oblast and District) and
the 300 inspectors of the Committee of Standardization and Metrology participate in
overseeing the iodized salt markets and trade in Kazakhstan. A draft Joint Order of the
Ministry of Health, the Ministry of Finance and the Ministry of Industry and Trade “On
Interactions of Monitoring of Import, Production, Storage, Transportation, and Sales of
Dietary Iodized Salt” is in the process of approval. Based on this Order, the information
63
gathered by the officials of the Committee of Customs Supervision on iodized salt import
and by the officials of the Committee on Technical Regulation and Metrology on
conformity or endorsement of iodized salt to technical standards will be combined in a
coordinated database, maintained by the National Committee on Sanitary and
Epidemiologic Supervision in the Ministry of Health.
176. All territorial and district staff of SES under the Ministry of Health received
training on the methods for inspection of iodized salt in 2004 with repetition in 2006
through cascade workshops. In 2004, with repetition in 2006, territorial and district
officers of the Customs Committee under the Ministry of Finance received training on
border control of import and export of iodized salt through cascade workshops. In
addition, with the purpose to prevent import of non-iodized salt, the officers were
provided with kits to perform spot tests at the customs points on the country’s borders.
Finally, also trainings of territorial/regional staff of the Committee on Technical
Regulation and Metrology of the Ministry of Industry and Trade were carried out in 2005-
2006.
F. Kyrgyz Republic
1. Supply
177. At the start of the JFPR9005 project, 3 salt enterprises were processing
consumer salt in the Kyrgyz Republic, together supplying ±5,300 ton of iodized salt
(SSA, Table 1) and salt imports, mostly from AralTuz in Kazakhstan, constituted ±70% of
the national salt consumption at that time. By 2005, the MICS carried out by the National
Statistical Committee showed that 76% of the households were using adequately iodized
salt. By early 2006, the technical, training and material support of JFPR in collaboration
with local partners had assisted in growing the number of local salt processing industries
and in 2006-2007, 10-12 small and medium-scale local salt enterprises supplied on
average ±13,000 ton of iodized salt per annum, or 75-80% of the estimated national
consumption need. With the trend in Kyrgyzstan toward adoption of World Trade
Organization (WTO) rules, the increasing domestic salt supplies also became
complemented by a more diverse range of foreign salt supply sources in Kazakhstan,
Belarus, Uzbekistan and Tajikistan.
178. As described, the supportive role of the Kyrgyz Salt Producers Association
(KASP) had grown from the previous JFPR project period, and although not all the salt
enterprises in Kyrgyzstan became a member of KASP, the association remained a
useful conduit for training, resources and coordination, and they represented the
interests of the industry in the National Fortification Alliance. Supported by JFPR and in
coordination with KASP, the salt enterprises were increasingly adopting the WYD
checker for in-process quality assurance of their product. Disappointingly, however, the
government agencies did not recognize the validity of the results obtained with the WYD
instrument in the industry. In 2006, the Kyrgyz Government waived the import taxes on
fortificant and salt iodization equipment. In 2006 and 2007, JFPR in collaboration with
KASP organized two capacity training workshops on quality assurance for salt
technologists, each with an attendance of 25-30 people. KASP also started an effort of
purchasing the fortificant on behalf of its members, but the activities of the Association
became less tangible upon de departure of the founding chairman in early 2007.
64
2. Demand
179. As described before, the Kyrgyz-Swiss Health Project had started in 2002-2003
supporting the village health committees and the primary health care workers in Naryn
Oblast with their use of the rapid salt test kit as a tool to persuade the local traders and
retail shops to accepting only iodized salt from their suppliers. A follow-up assessment in
2005 showed a quantum leap in the supply of iodized salt in the Oblast. Using test kits
that react with potassium iodate only, the massive salt testing campaign also succeeded
in reducing the share of salt that was still iodized with the less stable potassium iodide to
virtually nil. With JFPR and UNICEF support, the “market raids” were extended to a
number of other Oblasts in Kyrgyzstan with similar success in raising the consumption of
iodized salt. In 2006 and 2007 for example, raids were conducted in Issyk Kul, Bishkek
and Chui Oblasts. The effect of these tests was that the salt traders quickly learned that
substandard non-iodized salt, even if labeled as iodized, or salt with the less stable
potassium iodide, did no longer sell well. In addition to the educational effect among
consumers, the test kits were also distributed widely among the retailers and traders,
who were using the test at wholesale when they purchased salt. Competing for market
share is a challenge that salt producers quickly understand, and each processing
enterprise needed to adjust by iodizing their salt with potassium iodate, or else loose
money. The innovative use of test kits became a driving force in Kyrgyzstan for
consumer insistence on the product and for enforcing the agreed strategy upon the
suppliers, and thus, the supplying industry. Despite the weakness in the official
enforcement and the overall failure of governance, the salt producers were being
pressured to provide a product that the consumers and traders insisted upon with a
simple test.
3. Regulation
180. The major legislation and regulatory arrangements for USI had already been
enacted in Kyrgyzstan at the start of JFPR9052. During most of 2006-2007, managing
the JFPR project was handicapped by the lack of a decision by the Government to agree
on a composition of the Steering Committee. Also, the Kyrgyz Government was the
single entity that did not actively lobby for a project extension when the official 25-month
period of JFPR9052 ran out. In 2006, the Ministry of Education, Science and Youth
issued an order that the school catering should use fortified foods (flour and salt) and
also, as mentioned above, the taxes on the import of fortificant and iodization equipment
were waived during that year. In view of the above-described developments in
enforcement practices during 2006-2007, however, completing an effective sustainable
legislative framework proved a challenge in Kyrgyzstan. The project continued
supporting the in-process measurements of salt quality by technicians using titration and
the WYD checkers, the results of which in the course of 2006-2007 invariably reported
100% adequacy. Also the measurements by the SES inspectors using titration and WYD
checkers in the markets received support, and the results for 2006-2007 showed
generally adequacy levels around 80% of the mandated iodine content.
G. Mongolia
1. Supply
181. The challenge in progressing to universal quality iodized salt supplies in
Mongolia throughout the JFPR9005 period had been in striking the right balance
between giving adequate attention on the one hand to the salt import for the more
65
populous central area of the country, and the efforts to support the domestic production
of iodized salt in remote provinces on the other. A count of the supply sources listed 10
significant enterprises in remote provinces (Figure 9) while in the capital Ulaan Bataar, 4
salt processing enterprises processed raw salt imported from China and supplied approx
88% of the domestic consumption.
Figure 9: Locations of Major Salt Deposits in Mongolia
182. The MICS results of late 2005 showed that 74.6% of the households were using
adequately iodized salt in Mongolia and the 3rd National Nutrition Survey, conducted in
2004, had identified the lowest iodized salt consumption as well as the lowest iodine
nutrition status in the Western Aimags. The Mongolian government thus maintained a
major emphasis during JFPR9052 on efforts to improve the capacity for quality iodized
salt supplies in the Western domestic enterprises. A feasibility study coordinated by the
Salt Producers Association demonstrated the potential of small salt enterprises in Uvs
and Zavkhan Aimags of Western Mongolia for localized iodized salt supplies. JFPR
provided technical assistance, inputs and training of the company staff, and promoted
the involvement of the health sector and hospitals in ensuring adequate availability.
Several support visits were made by JFPR project officers to stimulate the production
management, quality assurance and marketing of quality iodized salt by the enterprises
in Western Aimags that were assisted with improved salt harvesting basins, processing
equipment and laboratory technology (Figure 10). An analysis of productive capacity by
the end of the project indicated that the JFPR investments had reached the full ability to
supply the agreed amount and quality of the domestic consumption needs.
183. During the JFPR9052 period, also the number of quality tests on production
(including the share from processors of salt imported from China) was stepped up and
showed that more than 98% of the production was according to the mandated iodine
66
content of 30±5mg/kg. Stimulating self-procurement of inputs by the salt processing
enterprises did not succeed, however, mainly due to the continued free supply of the
fortificant during the project period from another agency source.
Figure 10: Side-laboratory of the Salt Processing Plant in Ulaangom, Uvs Aimag,
Mongolia
2. Demand
184. The project in Mongolia continued working with NGO and government partners in
promoting the acceptance and awareness among the public of the value of iodized salt.
Support was channeled through National IDD Day rallies in 2006 and 2007 at various
locations in Mongolia, including the Western Aimags. The use of the Healthy Food logo
continued being promoted. The products of Zavkhan Baylag company, one of the project
beneficiaries, was given high exposure through a special award from the Ministry of
Food and Agriculture at the 2006 National Food Expo in Ulaan Baatar. In many of these
events, school children were involved in testing and demonstrations. The task of
inserting information on IDD and salt iodization into the educational curriculums was not
accomplished, however.
3. Regulation
185. In the course of 2005, the various entities for food and product inspections were
abolished and Government announced a new State Specialized Inspection Agency
(SSIA) to encompass the previously less-coordinated various agencies. During
JFPR9052, the project worked with the new SSIA in organizing workshops and on-site
visits to the borders and Western Aimags to improve on the control functions and routine
inspection procedures to ensure quality iodized salt supplies in the markets. The project
also strengthened the capacities of SSIA laboratories by supplying equipment and
chemicals. The salt testing in local markets showed high accordance of the salt
accessible by the population with the mandated standard.
67
186. Overall in Mongolia, there has been good collaboration between the Ministry of
Health and the Ministry of Food and Agriculture throughout the two JFPR periods,
though the idea of forming a National Coalition never came to full fruition. Instead of the
national level, however, local nutrition teams were formed and they proved helpful in
creating and maintaining local initiatives, including TV and radio broadcasts, shaped to
fit the area-specific circumstances. As to managing the policy efforts for USI in Mongolia,
a National IDD Council was already in effect dating before the JFPR project and this
assisted in the development of plans under a 2nd National IDD Program, which was
helpful in curtailing the imports of non-iodized salt from China. The Government of
Mongolia launched a 3rd National Program on Prevention of IDDs in April 2007.
H. Tajikistan
1. Supply
187. The salt industry in Tajikistan at the start of the JFPR project consisted of 3 large,
state owned industries: (a) Koni Namak in Asht, Soghd Oblast (300km North of
Dushanbe), (b) Namaki Yovon, RRS (60km South of Dushanbe) and (c) Khodja Mumin
in Vose, Kathlon Oblast (180km South-East of Dushanbe). In addition, two private
processing industries became established during JFPR9005, both in Vose, Kathlon
Oblast, namely AO Dushanbe and Dilovar N. For 2006, the Association reported a total
production of iodized salt of 38,870MT with an estimated breakdown as follows:
• Koni Namak (Asht, Soghd Oblast) – 15,640MT
• Namaki Yovon (Yavan, RRS, Figure 11) – 7,040MT (producing only “Extra” salt)
• Khodja Mumin (Kathlon Oblast) – 11,600MT
• AO Dushanbe (Kathlon Oblast) – 2,250MT (Processing plant)
• Dilovar N (Kathlon Oblast) – 2,200MT (Processing plant)
Figure 11: The Namaki Yovon Salt Factory in Yavan, Tajikistan
188. Since the estimated national consumption need of Tajikistan is 35,000MT, the
above data indicate that the realized local production would be sufficient for reaching the
project goal. Issues being tackled during the early JFPR9052 period were the unsteady
iodized salt quality from the Koni Namak and Khodja Mumin plants, and the organization
of a large number of small salt excavation enterprises in Kathlon Oblast that did not have
capacity for iodization. In collaboration with local authorities and UNICEF, the project
managed to unite these small firms into 7 producer cooperatives to contract them on
68
continuous basis to deliver their production to the Duhanbe and Dilovar processing
plants. Although initially the intent was that the Khodja Mumin plant would be the
location for iodizing the salt produced by the cooperatives, the processing conditions in
this old Soviet plant had become utterly obsolete. A supervision visit to AO Dushanbe in
November 2007 (Figure 12) confirmed that the plant was fully operational. The records
of production and quality assurance in a dedicated side-laboratory showed that the
supplies were kept in the mandated range of 25-55 mg/kg iodine content. The lab
logbook, furthermore, had information of regular external inspections by the health and
industry authorities.
Figure 12: Salt packaging at the AO Dushanbe enterprise in Kathlon Oblast,
Tajikistan
189. A Grain Processors and Salt Producers Association had been registered officially
in Tajikistan during 2004. Using JFPR guidance and an initial donation of 1,350kg
potassium iodate by UNICEF, the Association had set up a revolving fund for facilitating
the supply of potassium iodate to the 5 active salt enterprises. In mid 2006, the
Association entered into an agreement with a Russian supplier to provide staggered
deliveries of the fortificant over a period of 1 year. This allowed the Association to sell
the fortificant for US$35/kg to the salt producers, excluding the handling costs incurred.
To be able to charge these costs, the Association was seeking re-registration as a for-
profit company, and in the mean time, JFPR covered the handling costs to keep the
potassium iodate revolving fund going. While this was happening, the Ministry of Health
approached the Government twice with a request to abolish the tax on the import of the
fortificant. In both cases, the request was turned down by the Ministry of Finance on the
ground that the producers made a profit from their sales of iodized salt.
190. The internal quality tests by producers during the years 2006-2007 showed
adequate iodine content for 95-100% of production. Titration and WYD checker results
of the tests by SES in the markets for 2007 also showed that >95% of the salt for sale to
consumers was properly iodized. During early 2007, SES conducted special tests in
Kathlon Oblast, finding that 86-94% of the salt in the markets and 84-89% in the
households tested adequately, indicating that the efforts by the project and the Society
Forum to improve on the quality of iodized salt supplies had started being successful.
69
2. Demand
191. The JFPR project hired 2 consultants for organizing the communications efforts
in support of the USI and flour fortification goals. Communications materials were
developed collaboratively, with involvement of subject specialists from Government and
applied in coordination with marketing efforts by the salt industry. The major importance,
however, was that the communications campaign mobilized more effective action to
overcome the known barriers in USI achievement in Kathlon (and RRS) Oblasts.
Specifically, Civil Society Forums held in Kathlon Oblast were excellent examples of the
needed communications efforts to overcome barriers in USI achievement from the
leakage of non-iodized salt in the markets. The Oblast Forums and the subsequent min-
Forums in the Khamadoni and Vose districts of Kathlon are described in some detail in
the summary prepared by the CPO, and therefore, will not be repeated in this report.
Another ADB-sponsored project “Community Participation and Public Information
Campaign for Health” would continue the funding of this component upon termination of
the JFPR project, thus ensuring continuation of the mobilization at grassroots level.
3. Regulation
192. The USI mandate in Tajikistan had already been achieved in December 2002 by
the enactment of a law on salt iodization, which had been enabled by a Government
Decree of one month earlier that launched the Health Strategy for Tajikistan, 2002 –
2010. As was the case in the other Central Asian countries, Tajikistan in March 2004
adopted the previous Soviet GOST standards for the definition, use and inspection of
potassium iodate and the end product in iodized salt manufacturing. No other main acts
or subsidiary regulations were enacted during the JFPR9052 period. The project
supported training of salt factory technicians, SES specialists and Standards agency
officials during 2006-2007.
I. Uzbekistan
1. Supply
193. The continued delay in the enactment of the USI law caused the project activities
in Uzbekistan to come almost to a standstill during much of 2005-2006. Equipped with
technology and provided with potassium iodate, the 13 selected salt industries continued
with producing iodized salt in the interim period, however. In-process quality testing by
titration and WYD invariably showed full compliance with the previous Soviet GOST
standard, which was adopted in September 2005 by the State Agency on
Standardization, Metrology and Certification. The Government of Uzbekistan in the end
enacted a Law “On IDDs Prevention” in May 2007, giving central importance to salt
iodization, while also including clauses that individual, group and mass prophylaxis were
permitted with pharmaceutical preparations prescribed by the medical profession.
194. Pressed by the project, the Ministry of Health in early 2007 released information
that 19 industries were producing salt and another 28 firms were engaged in packaging,
labeling and sales of salt purchased the from primary producers. The 13 salt industries,
selected for project support since 2002, constituted about two-third of the national salt
supplies. The Salt Producers Association, promoted by Government during the previous
JFPR period, did not manage to obtain an import license for potassium iodate and it
ceased playing a role in the course of the JFPR9052 period. As an alternative,
70
centralized potassium iodate purchases were being arranged under Uzmedimport, the
official agency under the Ministry of Health.
2. Demand
195. Early during the JFPR9052 period, the NGO Kamalot, a national Youth
Organization, was selected for conducting information and advocacy activities. Working
with the GAIN-sponsored wheat flour fortification project, the JFPR project in May and
June of 2007 sponsored a series of youth festivals organized by Kamalot in several
provinces to promote fortified foods. The campaign was widely covered in national TV
and local newspapers.
3. Regulation
196. As mentioned above, the Law on IDD Elimination was enacted by the Uzbek
Government in May 2007. This was preceded in March 2007 by a Presidential Decree to
waive the import tax on salt iodization equipment. The salt quality inspections by SES in
markets and shops of Uzbekistan reached the largest number among the JFPR
countries. More than 51,000 titration and 4,200 WYD tests showed that almost 90% of
the salt for sale to consumers was iodized according to the GOST standard. It is
unknown whether the effort to insert knowledge of IDD and USI were successfully
completed during the JFPR period.
J. Stocktaking in preparation for the Almaty Forum 2007
197. During the 3-year period since the Almaty Forum 2004, the Asian Development
Bank through the JFPR9052 project delivered coordinated assistance and support to
accelerate the supply, demand and regulation of salt iodization in five participating
countries: Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan. Building
on the management networks established during the first JFPR period, the project
continued its collaboration with UNICEF and other partners for developing the capacity
in private and public sectors to deliver quality iodized salt, promote modern regulations
and incentives that facilitate production, sales and trade in iodized salt, and enhance the
public acceptance of the importance of sustained iodized salt consumption. Reports by
the Producer Associations in Kazakhstan, Kyrgyzstan, Mongolia and Tajikistan, and the
Ministry of Health of Uzbekistan indicate the shares of the projected national salt
consumption needs that were iodized during the 2003 to 2007 period (Figure 13).
71
Figure 13: Reported Iodized Salt Supply in Central Asia and Mongolia, 2003-2007
(% of estimated annual salt consumption requirement)
198. Overall, the two JFPR periods achieved on average 85% iodization of the
estimated salt consumption of the population in the participating countries. The shares of
iodized salt varied appreciably among the JFPR countries, however, with Tajikistan
(128% on average) and Kazakhstan (118%) achieving each a supply surplus,
accompanied by shortfalls in Kyrgyzstan (71% on average), Uzbekistan (62%) and
Mongolia (56%). This is in line with the export positions of Kazakhstan and Tajikistan,
which would have particularly benefited the import of salt into Kyrgyzstan. The shortfall
in Uzbekistan relates to the fact that the EA elected to collaborate with 13 selected
producers who commanded up to two-third of the national market. The reported
achievement in Mongolia suggests that a sizable share of the imported salt continued
reaching the consumption market without it being iodized.
199. The project not only made a significant contribution in ensuring the iodization of a
major part of the salt supplies; it also contributed in a determined effort to shift the
responsibility for the procurement of production inputs to the salt industries themselves.
In so doing, two mechanisms stand out, namely (a) the establishment and strengthening
of Salt Producer Associations and (b) the facilitation of direct relationships between the
salt industries with reputable outside suppliers of the fortificant, modern salt technology
and expert information. At completion of the JFPR9052 project, Salt Producer
Associations were evident in Kazakhstan, Kyrgyzstan, Mongolia and Tajikistan, each
playing a member role in national-level arrangements of coordination and oversight. And
an illustration of the shift in self-responsible procurement is that the associations and salt
industries reported purchase of potassium iodate during the JFPR9052 period at a value
of ±US$75,000.
72
Table 12: Estimates of Household Use of Iodized Salt and Brain Protection among
Newborns, JFPR Countries, 2000 and 2006
Population in
Household
millions Annual births in thousands a
Salt
protected %iodized per 1,000 total number number
Total against ID Value Year population number protected unprotected
JFPR9005 countries, end 2000 situation
Kazakhstan 14.9 4.3 29 1999 14 207 60 147
Kyrgyz Republic 4.9 1.3 27.2 1997 22 109 30 80
Mongolia 2.5 1.1 45 1998 20 51 23 28
Tajikistan 6.4 1.3 20.2 2000 21 134 27 107
Uzbekistan 24.8 4.7 19 2000 23 570 108 462
53.4 12.8 24 1,071 248 823
Data sources: Salt Situation Assessments; UNICEF 77%
JFPR9052 countries, 2005-6 situation
Kazakhstan 15.3 14.1 92 2006 18 275 253 22
Kyrgyz Republic 5.2 4.0 76.1 2006 21 109 83 26
Mongolia 2.6 1.9 74.6 2005 18 47 35 12
Tajikistan 7.0 3.2 46.4 2005 30 210 97 113
Uzbekistan 26.2 13.9 53.1 2006 23 603 320 283
56.3 37.1 66 1,244 789 455
Data sources: MICS surveys late 2005 and early 2006 37%
a
Population sizes and crude birth rates from the UN Population Reference Bureau publication for the respective years
200. Because the JFPR9052 period put higher emphasis on ensured quality of the
national iodized salt supplies, the capacity of the salt industries to perform in-process
quality assurance became a central theme. The record shows that the WYD
spectrophotometers, provided by JFPR, were valued and increasingly utilized by the salt
production managers of the industry. Nevertheless, in all countries except Kazakhstan,
the producers reported also using the rapid test kits for checking the production despite
its known inability of producing accurate measurements of the iodine content. Similarly,
records of the salt inspections in the markets and retail outlets indicate that the food
authorities, especially in Kyrgyzstan and Uzbekistan, also adopted the WYD equipment
although titration remained the main method for measuring iodine content, both at
production as well as in the markets and shops.
201. With the production stimulated and the quality of the supplies increasingly more
certain, what evidence can be provided that the consumption of iodized salt increased in
the JFPR9052 period? As an alternative to direct evaluation data, a “best available”
estimate for the populations of participating countries is available from the MICS surveys
conducted approx. 1 year into the JFPR9052 period. Compared to the situation in the
year 2000, the use of iodized salt in the JFPR9052 countries according to the MICS data
increased from 24% to 66% of the households by the mid-JFPR9052 period. This
indicates that by early 2006, or 1½ years before the closure of the project, almost 25
million new consumers of adequately iodized salt had been added in Central Asia and
Mongolia combined. During the same time period, the share of newborns exposed to the
risk of brain damage due to iodine deficiency fell from 77 to 37%. The Figure below
shows the sizable increase in the estimated numbers of newborns protected against the
risk of brain damage risk by the supply of quality iodized salt. A simulation with the use
73
of the PROFILES spreadsheets at GDP/capita (purchasing power parity) data of 2007
yielded an estimate of the savings as a consequence of iodine deficiency in the area that
amounted to US$300-350million each year.
Figure 14: Numbers of Newborns Protected each year against the Risk of Brain
Damage from Iodine Deficiency, JFPR Countries, 2000 - 2006
1. Sentinel Studies
202. The Sentinel Studies coordinated by the KAN in each country were aimed at an
evaluation of the potential effectiveness of the JFPR projects in pilot areas (2 pilot areas
per participating country) selected at the outset of JFPR9005. In each area, 40
households sampled randomly with a woman of reproductive age (15-49 years of age)
and at least two children (aged 2-15 years) were included in 3 rounds of data collection:
A baseline study in 2003 (December 2002 to April 2003); a 1-year follow-up study in
2004 (May to August 2004) and a 4-year follow-up study in 2007 (2nd and 3rd quarter of
2007).
203. During each round, interview information was collected of the acceptance and
use of iodized salt in the households and the iodine concentration in a casual sample of
urine, which reflects the iodine consumption, was measured of the children in each
round, and of the women in the rounds of 2004 and 2007. The Sentinel Studies
encompassed biological assessments of the effects of flour as well as salt fortification.
The results of the major iodine-related indicators are summarized in Table 13.
204. Comparison of the data in children in 2003 and 2004 demonstrate that an
immediate effect of the increases in iodized salt supplies on the iodine status of children
took place in most JFPR countries: One year after the 2003 baseline, there were
significant increases in the median urinary values in children in each country except
74
Mongolia, and taken all data together, the urinary iodine excretions more than doubled
(From 96 to 191µg/L) within that first year. The values in children for 2007 indicate that
these improvements were sustained, and also included Mongolia at that point in time.
The percentage of urinary iodine values below 100µg/L in children indicate the same
finding: While at the time of the 2003 baseline, half the children had values indicative of
iodine deficiency, their iodine status had improved by 2004 (one quarter below 100µg/L)
and by the 2007 round, the improvements were persisting. A similar finding applies to
the measurement of urinary iodine status among the women: The urinary iodine
indicators of 2004 and 2007 indicate sustained improvements of their iodine status,
which is accompanied by the salt measurements that suggest the continued
improvements of access to adequately iodized salt between 2004 and 2007 in the
sentinel sites. In summary, therefore, the assessments of iodized salt supplies and
iodine status among the households in the favorable pilot areas of JFPR countries
indicate that the iodine status of household members improved sizably and immediately
upon the supply of iodized salt, and these improvements in iodine supply and nutritional
status proved durable throughout the JFPR9052 period.
Table 13: Summary of Findings of the Sentinel Studies in JFPR Countries in 2003,
2004 and 2007
Median urinary iodine (µg/L) in 2-15y-old children in JFPR countries, 2003-2007
Year AZE KAZ KYR MON TAJ UZB All countries
Median 2003 155 105 79 69 29 109 96
urinary 2004 308 247 133 59 94 247 191
iodine 2007 324 188 - 119 120 137 168
Summary of median urinary iodine (µg/L) in 2-15y-old children, all JFPR countries
2003 2004 2007
Number 406 388 387
Median 96 191 168
% below 100 51.7 25.8 25.3
Median urinary iodine (µg/L) in 15-49y-old women, all JFPR countries
2004 2007
Number 196 182
Median 141 168
% below 100 26.5 21.4
Percent of household salt adequately iodized (≥15ppm)
2004 2007
AZE 70 100
KAZ 83 84
MON 60 100
TAJ 63 80
UZB 62 79
2. National iodine surveys
205. National iodine surveys represent an additional information source to explore the
changes in iodine supplies and iodine nutrition status that took place in Central Asia and
Mongolia during the years 2001-2007. Although the planned survey in Tajikistan did not
75
unfortunately produce reliable results, two national surveys are available close to the
end of the JFPR9052 period, one in Kazakhstan in 2006 and the other in Kyrgyzstan in
2007, both sponsored by UNICEF. Each survey collected data of the quality and use of
iodized salt in the households and they assessed the iodine nutrition status among a
representative sample of the population.
3. Kazakhstan 2006
206. In Kazakhstan, a National Micronutrient Survey was carried out in 2006,
associated with the MICS. The design of the MICS consisted of a stratified two-stage
sample of households, with regions as the main sampling domain for distribution of 625
clusters proportionate to population size in the urban and rural areas of each region. At
the second sampling stage, 24 households were selected randomly in each cluster, thus
yielding a variable number of households in each region. Successful interviews were
completed in 14,546 households and complete questionnaires were obtained of 14,570
women aged 15-49y, a response rate of 96.2 percent. Household salt samples were
tested with a rapid test kit in 14,426 households and by this method, 92.0 percent of the
households in Kazakhstan were found using adequately iodised salt. This result was
used in the Table above to estimate the number of newborns protected against brain
damage from iodine deficiency in Kazakhstan in 2006.
Figure 15: Frequency Distribution of Iodine Content in Household Salt,
Kazakhstan 2006
207. The National Micronutrient Survey was conducted from March to May 2006 on a
systematic sub-sample of 5,000 15-49y-old women, or every third household of the
MICS sample, to collect data of their food consumption, blood haemoglobin and
excretion of iodine in urine. Salt and urine samples were collected from a systematic
sub-sample of ±1,000 households (every fifth of the sub-sample of women in the
Micronutrient Survey). Quantitative urine and salt iodine assays were carried out in the
iodine laboratory of the KAN, which was participating successfully in the urinary iodine
quality management program of CDC, Atlanta. The frequency distribution of iodine
content in household salt (Figure 15) is slightly skewed to higher values and it has a
small but discernable shoulder at the low end. The median salt iodine content was 25.6
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mg/kg, with inter-quartile range (IQR, the range from 25th to 75th percentile) 15.1 mg/kg.
The majority (90 percent) of salt iodine contents varies between 6.2 and 48.1 mg/kg.
Using the agreed-upon threshold of 15 mg/kg, 86.9 percent of the households were
using adequately iodized salt.
Figure 16: Urinary Iodine Excretions in Women of Reproductive Age, Kazakhstan
2006
208. Similar to the household salt iodine content, also the distribution of urinary iodine
in the women (Figure 16) is skewed to higher values. The median UI was 249.5µg/L and
IQR 195.5µg/L. The majority (90%) of the UI values vary between 45 and 577µg/L. Of all
the UI measurements, 52.1 percent were encompassed in the range of 100– 300µg/L. UI
<100µg/L was found in 13.6 percent of women, UI <50µg/L was found in 5.1 percent,
and 1.8 percent was <20µg/L. The results confirm that the women, who were
representing the situation of the population, had an optimal iodine status.
Figure 17: Changes over Time in the Household Use of Iodized Salt in Kazakhstan
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209. In Kazakhstan, national surveys had been conducted in the period 1999-2006 of
the use of iodized salt in the households. Figure 17 shows the improvements in the use
and quality of iodized salt observed in the households during this period. From 1999 to
2004 (dashed lines), the salt iodine levels were assessed in terms of all iodized salt,
while from 2004 to 2006 (solid lines), the surveys were also assessing specifically for
adequately iodized salt – i.e., the salt that visually tested ≥15ppm. Between 1999 and
2004, the use of iodized salt in the Kazakh households rose from 29 to 89%, and in the
period between 2004 and 2006, the coverage of households using adequately iodized
salt increased from 83 to 92%. Noteworthy, the reductions in the household coverage
rate in Almaty City and southern region from 2004 to 2006 were offset by the sizable
increases in the household usage rates in the northern and eastern regions over the
same time period.
210. The increases from 1999 to 2006 in the use of iodized salt by the households in
each region were accompanied by sizable reductions in the fraction of low UI values
among women of reproductive age. Whereas in 1999 more than half of the women had
UI<100µg/L in all regions except the centre, this was no longer the case in any of the
regions in 2006. The reductions in low UI values were apparent in each region and at
each cut-off point at the lower end of the UI distribution. In Kazakhstan overall, the
proportion of low UI values decreased from 53 to 14% at the conventional 100µg/L cut-
off point, from 24 to 5% at 50µg/L, and from 6 to 2% at 20µg/L. In 2006, the highest
share of UI values <100µg/L was 22.7% in Almaty City, and the lowest 1.8% in the
central region.
Table 14: Urinary Iodine Concentrations in 1999 (Demographic Health
Survey) and 2006 (National Micronutrient Survey), Kazakhstan
Urinary Iodine Concentrations in Women Aged 15-49y (µg/L)
Region
Year % below 20 % below 50 % below 100
1999 12.5 34.1 60.7
North
2006 1.1 3.8 13.3
1999 7.8 26.8 65.4
East
2006 2.2 7.2 13.0
1999 7.9 32.6 59.0
South
2006 3.3 8.4 16.0
1999 4.7 29.9 61.2
West
2006 0.0 1.7 15.0
1999 0.5 4.7 25.7
Central
2006 0.0 0.0 1.8
1999 3.7 18.4 52.2
Almaty City
2006 4.5 9.1 22.7
1999 6 24 53
Kazakhstan
2006 2 5 14
211. Based on the analysis of a national population-representative iodine survey in
2006, the iodine nutrition situation in Kazakhstan had reached the optimal level, and a
comparison with similar data collected in 1999 illustrated that the outstanding
improvement of iodine status in the population was associated with significant
improvements in the use and quality of iodized salt in the households. By 2006 also,
more than 90% of the households were using adequately iodized salt, an achievement
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that came about during the period that JFPR assisted the partners in Kazakhstan with
piloting, and then accelerating the supply, acceptance and regulation of salt iodization
for IDD elimination.
4. Kyrgyzstan 2007
212. A national, population-representative survey was conducted in Kyrgyzstan in
October-December 2007, collecting quantitative measurements of the iodine content in
household salt to approximate iodine consumption, while the iodine nutrition status was
assessed by measuring UIs and thyroid volume was measured by ultrasound to estimate
the burden of IDD in the population. The survey selected 30 primary schools
proportionate-to-population-size from the national database of school enrolments and in
each school, 30 children aged 8-10 years were sampled at random. The standard
school-based design was extended by enrolling also 20 pregnant women in each
selected school settlement. Pregnant women were sampled from the attendance list of
one or more nearby prenatal clinics. The salt brand name was recorded for the
household salt samples, and each child and women volunteered a urine sample. The
salt and urine determinations took place in the iodine laboratory of the Endocrine Center
in Bishkek, which participates successfully in the EQUIP urinary iodine quality assurance
program provided by the CDC, Atlanta.
213. During the survey, 27 different salt brands were collected, 21 of domestic origin.
Although non-iodized salt constituted only 2.1% of all salt samples, salt with iodine
content <15mg/kg constituted 60.5% of the household salt. 453 (50.3%) of the 900
school children were male. The 580 women in the survey were on average 22w
pregnant; 146 (25%) women were in their 1st, 223 (38%) in their 2nd and 211 (36%) in
their 3rd trimester. The basic iodine indicators are shown in Table 15.
Table 15: Iodine Indicators in Women and Children, Kyrgyzstan 2007
School-age Children (n=900) Pregnant Women (n=580)
Salt
iodine Urinary iodine Thyroid Salt iodine Urinary iodine Thyroid
content concentration volume content concentration volume
(mg/kg) (µg/L) (ml) (mg/kg) (µg/L) (ml)
Median 10.5 114 2.8 12.4 111 7.9
7.5 -
95% CI 9.6 - 11.5 106 - 124 2.7 - 2.9 11.0 - 13.7 102 – 121 8.1
5th
Percentile 1.5 30 1.6 0.9 30 4.1
95th
Percentile 67.3 399 4.7 66.0 452 15.6
214. The iodine content in the salt samples brought by the children or women did not
differ significantly. The median iodine content in all the salt samples was 11.2mg/kg
[95% CI: 10.5-12.0]. Similarly, no significant difference was found in the median UIs
between the 900 school children, 114µg/L [95% CI: 106-124] and the 580 pregnant
women, 111µg/L [95% CI: 102-121]. However, the thyroid volumes of the pregnant
women were significantly larger (p<0.001) than of the children. The goiter prevalence in
the children was 5.2% [95% CI: 3.9-6.9] based on the age-reference, and in women, the
thyroid volume increased with the duration of pregnancy (p<0.001).
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Table 16: Urinary Iodine Levels in Children and Pregnant Women by Supply
Source of Salt in their Households
School-age children Pregnant women
Salt supply source N Median [95% CI] N Median [95% CI]
Domestic 659 105 [98 - 113] 391 102 [92 - 120]
Imported 222 147 [126 - 176] 160 132 [111 - 169]
Figure 18: Urinary Iodine Distributions in Children and Pregnant women,
Kyrgyzstan 2007
215. Among the school children, 338 (43%) had a UI below 100µg/L and 224 (25%) a
UI of 200µg/L or above (Figure 18). UI <150µg/L was observed in 355 (61%) of the
pregnant women while 125 (22%) women had a UI ≥250µg/L (Figure 18). In both the
children and the women, the lowest median UI levels were observed in Chui and Naryn
provinces. Children in Batken and Talas province had the highest median UI, while the
highest UI in women was observed in Batken and Osh provinces. As shown in Table 16,
the urinary iodine in the children and women was significantly associated with the supply
source of their household salt. Compared to households using salt imported from
Belarus, Kazakhstan, Tajikistan or Uzbekistan, the median urinary iodine was lower by
30-40µg/L among the survey participants from households using domestically produced
salt.
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Table 17: Urinary iodine concentrations in school children and pregnant women
by iodine content in the salt in their households, Kyrgyzstan 2007
School-age children Pregnant women
Salt iodine Median, 95% Percent Percent Median, 95% Percent Percent
level N CI <100µg/L ≥200µg/L N CI <150µg/L ≥250µg/L
0 - 4.9mg/kg 248 106 [86 - 126] 47 22 141 83 [71 - 97] 75 11
5 - 14.9mg/kg 310 101 [89 - 111] 49 18 196 106 [89 - 127] 63 19
15 - 24.9mg/kg 111 135 [106 - 165] 36 29 88 140 [111 - 174] 55 25
≥25mg/kg 231 149 [124 - 168] 34 35 155 156 [126 - 202] 50 32
216. As is the case in the other countries of Central Asia, Kyrgyzstan has adopted the
CIS-wide standards for salt iodization of 40±15mg/kg. To analyze whether this standard
would be adequate for attaining optimum iodine nutrition throughout the population, the
survey data of the school children and pregnant women were used to examine their
iodine status in relation to the differing levels of salt iodine content (Table 17). The
improvements in the UI medians among the survey participants along with the stepwise
increasing levels of salt iodine content illustrate their significant responses in iodine
status to the level of iodine in their household’s salt. The iodine status among pregnant
women attained the level considered adequate for their dietary requirement in those
households where the salt iodine content was ≥25mg/kg. This analysis illustrates also
the shifts at the margins of the UI distributions that occurred with the stepwise increases
in salt iodine content. Comparing the top and bottom rows in the table above, the
majority of low (<100µg/L) UI values present among children in the households using
salt with the lowest iodine levels changed to an evenly balanced proportion of low and
high UI values among the children of the households with salt iodized at ≥15mg/kg.
Similarly, the sizable predominance of low (<150µg/L) UI values among the pregnant
women consuming salt iodized at the lowest levels was attenuated to 50% low values
among the women in the households using salt with 25mg iodine/kg or above. It would
therefore appear that the mandatory level of iodization set by the Kyrgyz authorities is
adequate for an iodized household salt supply that can lead to optimum iodine nutrition
in the population.
217. In summary, the national survey in Kyrgyzstan in 2007, carried out at the end of
the two JFPR periods, confirmed that much progress has been achieved in improving
the iodized salt supply and iodine nutrition status in the population. Regional surveys
among 10-12 year-old school children in Bishkek, Issyk Kul, Jalalabad and Osh Oblasts
from 1985 to 1988 had found median urinary iodine levels varying in the range of 25-
45µg/L and goiter prevalence between 33 and 86%. Spot tests of household salt with the
rapid test kit showed that iodine was absent in the majority of the salt consumed by the
population at that time. The survey results of 2007, therefore, document that significant
progress was made in reaching for USI, alleviating iodine deficiency and eliminating IDD
in Kyrgyzstan. The low share of non-iodized salt in 2007 illustrated that the campaigns of
testing salt in the communities have succeeded in signaling to the traders and producers
that they will suffer a loss of their market if no effort is made to iodize the product. At the
same time, however, the low percentage of salt that was iodized according to standards
indicated that many salt enterprises only added a minimal amount of the potassium
iodate fortificant during salt processing.
218. The survey in Kyrgyzstan had a number of unique features, one of which was
that pregnant women were enrolled for measurements of their iodine nutrition status, in
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addition to school-age children. The urinary iodine among the pregnant women indicated
that they did not consume sufficient iodine to satisfy their increased dietary iodine
requirements. The practice in the salt industry of minimizing the use of fortificant in
iodizing the salt, therefore, had the consequence that despite the apparently sufficient
level to meet the iodine consumption needs of school children, the supply was
insufficient to ensure that all the newborns are protected against the risk of brain
damage of iodine deficiency.
5. USI performance in raising iodine nutrition in JFPR countries
219. This section has summarized evidence obtained from four different origins to
indicate how effective the salt iodization efforts during the JFPR project period were in
increasing the supplies of quality iodized salt, raising the iodine status in the population
and decreasing the burden of IDD. The findings, even though not aligned in perfection,
are consistent with the expectation that the act of iodizing salt well at production leads to
improved iodine supplies and consumption throughout the population, which in turn,
improves the iodine status and decreases the extent and severity of IDD in poor and
vulnerable groups. Each of the four sources of information highlights a different aspect in
this logical chain of events. The producer-provided data suggest that on average 85% of
the edible salt supplies in JFPR countries were being iodized during the project period;
the MICS survey results show that on average 66% of the household salt was iodized
well in the midst of the JFPR9052 period; the Sentinel Studies in focused areas
demonstrated the potential in improved consumption and iodine status of vulnerable
population groups; and, finally, two national iodine surveys confirmed the outstanding
benefits in iodine nutrition and IDD reduction caused by the improved iodized salt quality
production and supplies.
V. THE ALMATY FORUM 2007
220. The 3rd Almaty Forum, held on 29-30 October 2007 represented the capstone for
the two successive JFPR projects. It marked the completion of six years of JFPR action
in organizing a combination of high-level presentations and exchanges of experiences
among the stakeholders in stimulating flour and salt fortification in their countries and
ended with an agreement (Appendix 7) on the range of key principles for moving forward
in the future. Almost 100 participants from Governments, flour milling and salt productive
industries, civil society and scientific institutes of the JFPR countries took part in the
presentations and discussions. They were joined by officers of ADB, JFPR, UNICEF,
CDC, GAIN, IAOM and FFI – i.e. the broad spectrum of agencies and interest groups
active in assistance and promotion of food fortification around the world.
221. The Forum offered reviews of accomplishments, including those reported for salt
iodization in the sections above. There was understandable emphasis, and a sense of
fulfillment with the fact that in JFPR countries, the enactment of principle laws mandating
universal salt iodization had mostly been followed by a varied range of activities aimed to
stimulate the completeness and quality of supply, improve the procedures in trade and
sales of iodized salt in and between countries, raise the acceptance and awareness
among the public, and produce evidence of improvements in household consumption
and iodine nutrition of poor population groups. Speakers from Government, science, civil
society and private industries joined in sharing examples of the progress made in these
various activities. Still, there was common realization that the efforts should be stepped
up and continue in order to sustain the benefits from salt and wheat flour fortification. As
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yet, only a few countries had attempted to execute a comprehensive, well-resourced
policy.
222. Fortification is a nutritional intervention that can sustain itself by established
habits, including the transfer of costs to the end consumer. Now also from Central Asia,
the evidence demonstrates that widespread deficiencies in the population can be
overcome by fortifying the common food supply. At the same time, evidence also tells
that the deficiencies will return when fortification is abandoned. Thus, to move forward
and achieve the goals of sustainable USI and flour fortification in the region, the Almaty
Forum 2007 devoted time to the formulation and agreement on a consensus statement
that aimed at permanent fortification programming upon the termination of the JFPR
period. At the end of the JFPR resource stream, the set of promises by the participants
in the Almaty Forum 2007 offered a hopeful perspective of their renewed determination
to carry on with the coordinated set of fortification activities that were learned from the
recent experiences.
VI. LESSONS LEARNED
223. The JFPR projects addressed a clearly relevant issue in national health
development with significant resources, an ambitious scope and an approach that was
new to the area. Supplying iodized salt was familiar: The previous Soviet directive to
guide iodized salt to areas documented with endemic goiter were part of the Central
Asian history. The idea of joint collaborative decision-making and management was
new, however. The demise of the former command economy meant that a health
development objective could no longer be imposed on a newly private sector. Logically,
therefore, the succession of JFPR projects started out with promoting the establishment
of national collaborative mechanisms under the leadership of Ministries of Health with
the aim to gather the principle stakeholders under one umbrella for coordination and
decision-making. And in those countries where the political will was evident, the follow-
on project was directed at a three-pronged effort to scale-up the amount and quality of
the iodized salt supplies toward a target that is known to be sufficient for eliminating the
problem. The outcome of the 1st period was that the key stakeholders had learned first-
hand that large-scale iodization was achievable by joint collaborative action; the 2nd
period established the benefit that can be gained from making universal salt iodization
happen, while quality assuring the product supply and monitoring the reduction of iodine
shortfalls in the diet.
224. The previous chapters have described the different extent that the JFPR
countries succeeded in completing this succession and illustrated the different outcomes
among the JFPR countries at the conclusion of the six year period. The present chapter
attempts to describe the key factors that played a role in the different uptake and
performance observed among the countries in response to the challenges and support
offered by the JFPR projects. The chapter ends with a summary of the key lessons
learned.
A. The conceptual approach
225. At the outset in 2001, the need was clear that national multi-sector committees,
or coalitions, were an essential part of the mixture for reaching success. The design
rationale followed an analysis of global experience, indicating that USI strategies can be
built upon three essential components: iodization, communications and monitoring. Each
component has a variety of elements that need being fulfilled:
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• Salt iodization implies adequate capacity and technology, secured input
procurement, quality assurance of production, market access, and product promotion
and customer sales
• Communications aimed at acceptance among the public, and provision of advocacy
to strengthen the national constituency and keeping opinions among the
gatekeepers positive
• Information monitoring involves the data collection and interpretation of inputs,
activities and results for multi-sector management, and the reporting about the
actions and their outcomes in alleviating the problem.
226. The three key components are interlinked and overlapping: Promotion of iodized
salt, for example, is an activity in both the salt iodization and communications
components, and inspections of iodized salt quality in the markets is a measure of the
performance in iodization while it yields data of supply monitoring. Successful
performance of each component depends on the progress of all elements and, in turn,
the success of the strategy demands coordinated progress of each component
simultaneously. This outline suggests that a single success factor for USI can only rarely
be identified in a given case.
227. The additional difficulty in assessing the performance of USI strategies is that the
development of adequate capacity in all the components is a necessary, but not
sufficient condition for success. In other words, each of the three components needed
investments, but having each established does not automatically mean that the strategy
will perform well and become the habitual norm. In addition to building and developing
capacity, a national collaborative mechanism should therefore be created to oversee and
ensure that salt iodization, communication and monitoring continue producing the results
aimed for. This can be done through joint management of the component’s activities
among the partners having responsibilities for their implementation. Hence there was
need for partnership, which in the case of the JFPR projects was configured as the
National Steering Committee.
1. Regional Round Tables
228. Regional Round Table meetings, i.e. the Almaty Forums, were built-in as the
anchor events for high-level interaction for the purposes of advocacy, exchange of
information and experience, learning of new insights, and brokering agreements
between the national stakeholders, the donor agency and the technical expertise
providers. The atmosphere in the successive Forums displayed the clear improvement in
comfort that took place among most of the team members in being part in multi-sector
exchange of facts and opinions, and working together toward acceptance and
agreement. The successive JFPR Forums also built a reputation of excellence among
other groups working in the international arena, and the 3rd Forum in 2007 became
accompanied by satellite events on promoting flour fortification organized by reputed
international partners of ADB.
229. The Almaty Forums afforded important opportunities for sharing the modern
knowledge and insights from research and development with high-level officials of
Government, captains of salt and flour industry and leaders of civil society. The science
of iodine deficiency had led to the realization among leading global experts that iodizing
the entire edible salt supply for human consumption was needed to prevent the damage
of intelligence potential in each new generation. The public health idea was new in the
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area and it deviated from the previously dominant focus on endemic goiter control.
Moreover, it shifted the role of providing a solution to the salt productive industry. The
evidence-based reasoning and its logic became embraced by many stakeholders. The
Almaty Forums therefore made important contributions in establishing acceptance and
will among the political leaderships, which became evident in the mandatory USI laws in
each country. An important facilitating factor for acceptance of USI laws was also the
inter-State agreement of 2001 among the Presidents of the Commonwealth of
Independent States that adopted the GOST standard for iodization which was familiar to
the agencies working in the health sector and the industry. And in Mongolia, the case for
acceptance of a mandatory USI law was prepared by previous assistance by JICA and
UNICEF on similar evidence-based advocacy.
230. The Almaty Forums contributed also in the wider understanding that the USI
strategy cannot be successful or sustained by a singular approach – all stakeholders
were required to play their roles and take their responsibilities for the components salt
iodization, communication and monitoring. The JFPR project supported the salt industry,
but it was insistent from the start that the improvement of supply capacity had to be
accompanied by similarly important actions to ensure the quality of supply, disseminate
knowledge and information, and track reductions in the dietary iodine shortfall.
Moreover, although Ministries of Health were identified as the focal agencies, the
strategy implementation approach promoted and discussed in the Almaty Forums left no
doubt that reaching success required more than a Ministry of Health-led intervention.
231. Concluding, the JFPR approach demanded blending of all the public-, private-,
scientific- and civic interests and capacities. The delay in some countries in establishing
Steering Committees during the initial years reflected the difficulties of sorting out the
rules of engagement and agreeing on the standards of conduct in a truly multi-sector
partnership. The political nature of the coalition model again became apparent at a later
stage when in Kyrgyzstan and Uzbekistan high-level Government delayed the
authorization of the composition in the National Steering Committees that had changed
due to a normal personnel turnover in stakeholder organizations.
B. Implementation
1. Promoting quality salt iodization
232. In addition to the arrangements for National Steering Committees, another
project element that led to delay during the first stage was the consolidation and
collective procurement of iodization inputs in the salt industries. The details of the salt
supply situation at the outset were too sketchy for a decision on the input needs and
productive capacity gaps that would permit the producers realize the supply target of 66
percent in each country. By the time that the technology consultant had completed an
inventory, nearly half of the initially planned JFPR9005 period had elapsed. Reaching
agreements on procurements in each country, followed by competitive bidding added
more time, and moreover, the delivery of inputs ran into a time delay due to the military
operations in the Gulf region.
233. In reaction, the project leadership worked on two fronts, namely reprogramming
of the timeline for the JFPR9005 grant disbursements, permitting an extension of the first
phase to 3 years, and preparing for a follow-up project, which necessitated intense
negotiations with the Government of Japan as the JFPR was meant for financing pilot
interventions and not to finance the second phase of the same project. Following
85
facilitation by CPOs with customs clearing, the inputs for salt iodization were in place in
most of the industries by summer 2003. The provision early in the agreements that one
third of the fortificant costs required to be reimbursed by the beneficiary enterprises was
brilliant. As to utilization of inputs, the comparison of baseline and 1y follow-up data in
the Sentinel Studies demonstrated the dramatic improvements in iodine status that had
occurred in the target areas by summer 2004, an observation which is in agreement with
the international experience that increases in consumption of iodized salt will lead to
immediate improvement of the iodine status in the population.
234. Although this cannot be clearly attributed to the JFPR projects alone, the 1st
JFPR period witnessed the establishment of Salt Producers Associations in each
country. Increasingly, these Associations became the spokespersons for negotiation and
agreement in the National Coalitions, thus facilitating a common voice of the producers
as well as a valuable partner in efficient decision-making.
235. Two key issues important to the salt producers were the quality of the product
and the acceptance of the product by their customers. Access to inputs, especially
fortificant, was promoted in two meetings fashioned to facilitate direct relationships
between the salt producers in JFPR countries and reputed international supply sources.
The Associations of Kazakhstan, Kyrgyzstan, Mongolia and Tajikistan each were
involved in some way in assisting individual salt industries in fortificant procurement, but
only the Association in Tajikistan progressed to initiating a revolving funding mechanism,
which in contrast to previous experience elsewhere proved to be viable, served the
interests of the collective salt industry, and assisted in a more dependable fortificant
supply. The project also provided WYD spectrophotometers that can swiftly produce an
accurate measurement of the iodine content in a salt sample, combined with hands-on
training of the technicians and their counterparts in food control agencies. The WYD
machines were valued highly by the industry, and reports of results from the salt
inspections in the supply channels indicate that the WYD machines were also used
extensively by SES officials. The transfer and establishment of new, relevant technology
was therefore another benefit of the project. Ironically, the results of WYD
measurements were considered invalid by the Kyrgyz authorities on the argument that
no approval was obtained for their use. The project records of salt quality testing in
Kazakhstan showed that titration of the salt iodine content remained the mainstay
method in that country in quality assurance by the producers as well as in quality control
by the SES authorities.
236. Another unique contribution by the project was in the development and use of a
well pretested and appealing common logo. The ready uptake and use in all the project
countries involved are another testimony of the creative character of the project and the
willingness among the industries and their partners of adopting state-of-the-art practices
in establishing trust and loyalty among the public. The point was made earlier that
demand creation was not a fundamental requirement to attain success under the
universal, mandated product supply that the project pursued. The logo represents a
“stamp of approval” in as much its use was contingent on the demonstration by
producers of quality and the verification by control agencies of adequate supplies. But
little evidence has been collected whether the logo, or communications component, did
indeed function in this way in the supply systems of the JFPR countries.
86
2. Conduct of communications
237. The previous pages has given a number of examples of the importance that the
communications campaigns played in extending the message, broadening the
constituencies for iodization and keeping any negative attitudes among opinion
gatekeepers at bay. The development and use of a unified “Healthy Food” logo was a
creative invention arising from the communications training. The component mobilized
NGOs into the action, while the NGO contribution helped spreading the message more
readily and swiftly among the public. The numerous communications materials exhibited
at the 2nd and 3rd Almaty Forums were testimony of the great amount of creativity
unleashed under this component. However, the operational effectiveness and
comparative contribution in the progress made in any country toward higher shares and
better quality of supplies remained underexplored. A most impressive example of effect
of this component was perhaps the repeated holding of Civil Society Forums in Kathlon
Oblast of Tajikistan, which assisted in the reduction of non-iodized salt leakages from
hard-to-regulate salt deposits in the consumer market.
238. The action by village health committees and primary health personnel in
Kyrgyzstan to quickly test the salt for iodine and exert pressure on the suppliers of non-
iodized salt was another way in which the significance of grassroots action became
apparent.
239. Another look at the role of “communication” is the question how the EA
performed in its advocacy to inform and convince the partners, stakeholders and
gatekeepers in each country. The extent to which the EAs utilized the advocacy provided
through the Almaty Forums, for example, remained undocumented and the impression
remains that this was perceived as a role for the communications specialists, rather than
a performance issue to be tackled by leaders of the overall strategy. Inserting the
essential knowledge of salt iodization into regular curriculums was part of most plans
reviewed at the JFPR9052 mid-term workshop, but this was accomplished successfully
in Kazakhstan only.
3. Improving regulation
240. The concept of “quality” played a central role in standards setting, regulation and
measurements to ensure that the public is supplied by an adequate daily amount of
iodine through the common diet. The concept became wider than may be justified when
in Mongolia, Tajikistan and Uzbekistan a discussion was growing that the iodine amount
in salt deteriorated from the dampness and impurities in the raw salt, thereby implying a
project responsibility in improving the salt quality at production. The project has, by and
large, been able to resist this distraction. International experience indicates that
iodization is possible of all grades and purities of salt at virtually any production scale.
The question of how much fortificant should be added given the decay of iodine content
in the trade channels has a technical solution. Moreover, as shared from the start at the
Almaty Forums, the stability of the potassium iodate fortificant is such that quality indices
of the raw salt are not relevant in operating the USI strategy.
241. The role of inspection authorities to verify the quality of iodized salt supplies has
throughout been a difficult issue to address. The project did not succeed in involving an
international consultant who could engage constructively in this key area. The Minsk
agreement had attributed the roles of setting and upholding standards to the Sanitary-
Epidemiological Services under the Ministry of Health and, furthermore, the Ministries of
87
Health were the EA of the JFPR project. These were among the reasons that JFPR
support was directed at building the capacity of SES. The inspection in markets is
essentially punitive and intends to discipline the industry for non-compliance. If this is
influenced by dishonesty, the process creates resentment and this led to a decision by
Parliament in Kyrgyzstan that inspectors were only allowed one visit a year to the salt
enterprises or markets, upon a 1-month pre-announcement. The experience in
Kazakhstan of a constructive role by the Standards & Metrology Authority in Kazakhstan
eventually offered the example of an alternative (or parallel) approach that aims at
stimulating the industry into self-responsibility to uphold the standards during
manufacturing. The other reason that the project should have connected earlier to the
Standards Authority of the Ministry of Trade and Industry is that they issue the required
certificate that is essential for cross-border trade. That this process of certification can be
more successful is illustrated by the twofold better quality of the imported salt in Kyrgyz
households during the 2007 survey.
242. The project succeeded in principle USI law enactments in all the participant
countries, although the importance of salt iodization in Uzbekistan was watered-down to
benefit the pharmaceutical industry. The record shows also that attendant regulations
were passed in most countries. The less than stellar success record in regulation was
therefore not due to stubborn refusal among lawmakers. In the ideal case, Kyrgyz
Republic should have attained USI levels comparable to Kazakhstan under the virtually
similar legal and regulatory frameworks. The different outcomes illustrate that exercising
and respecting the rules are as important as setting and enacting them. This point
comes back also to the earlier observation that the JFPR support to ascertain effective
control procedures should have benefited from external expertise familiar to the area’s
regulatory system.
243. True USI law intends to encompass all the salt that ends up in human nutrition,
including the salt used in the food processing industries. Along with the increases in
urbanization, the fraction of the edible salt supply that enters a population’s food
consumption via commercially processed foods becomes more important. Should
pregnant women be advised by their physicians to reduce their salt intake, the extra
iodine provided through processed foods reduces their risk of iodine deficiency during
the time that the developing fetus is most vulnerable. The findings of the iodine status in
Kazakhstan demonstrate that the food processing industries were using iodized salt,
while the same data from Kyrgyzstan indicate that the salt industry did not supply iodized
salt to the food industry.
C. Conclusion
244. This chapter summarized important experiences during the 2001-2007 JFPR
period in progressing toward the goal of >90% supply of quality iodized salt. Against the
background of a serious and widespread problem of dietary iodine deficiency at
baseline, the succession of projects clearly made a highly significant contribution in the
correction of iodine deficiency. By the end of 2007, based on large-scale representative
surveys, two-third of the total edible salt supply in the participant countries was
adequately iodized. This compares to only one-quarter of the salt supply in 2001, i.e. a
quantum leap occurred in the six-year period between 2001 and 2007, which added
25million new iodized salt consumers in the area and protected 800,000 newborns each
year against the risk of brain damage from iodine deficiency. The economic losses
prevented from the improvements in iodine supplies approximate 300million US$ a year
for the 5 JFPR9052 countries combined.
88
245. This review of experiences emphasized the exemplary concept at the outset, and
the well-thought out and responsive stages in execution. It is also argued that the major
factor for success in Kazakhstan has been that the EA created and sustained a
partnership culture that stimulated the salt industry to take self-responsibility for the
habitual universal supply of adequate quality iodized salt to their customers.
246. Sustainability is a loaded idea: Only time will tell whether the JFPR period was
the beginning of a habitual norm among the salt industry and its counterparts to maintain
optimum iodine supplies for the population’s food basket. That the laws on salt iodization
in the area are mandatory certainly helps as it represents official policy. What has not
been covered during the six-year supply-oriented project period is the establishment of a
regular surveillance system that monitors the iodine nutrition status in relation to quality
iodized salt supplies. True impact evaluation, however, makes sense only after USI
becomes practice. For the JFPR projects in Central Asia and Mongolia, the main task
was to make that happen.
Appendix 1 89
JFPR 9005: ADB/UNICEF/KAN
Improving Nutrition of Poor Mothers and Children in
Asian Countries in Transition
A Salt Situational Analysis
SUMMARY of 6 Country Surveys
The present summary is based on reports of a coordinated SSA in 6 Asian countries in
transition, conducted during July 2001.
A. Production data
1. In all countries except the Kyrgyz Republic, the reports identified between 1 and 6
industries that produce edible (food grade) salt. In Kyrgyz Republic, three companies are
iodizing salt that is imported un-iodized mainly from Kazakhstan. In Turkmenistan (locally
produced salt) and Azerbaijan (salt is largely imported mainly from Ukraine), the estimated
national needs for edible salt are largely met from the supplies reported.
Estimated Delivery of Edible Salt by
Mid 2000
National Salt Companies Surveyed
Population
Country Edible Salt Need 1 (% of Estimated Need)
(Million)
(MT/Annum)
10% produced in country
Azerbaijan 7.7 40,000
85% imported
Kazakhstan 14.9 77,000 45% produced in country
5% produced in country
Kyrgyz Rep. 4.9 25,000
55% imported
Tajikistan 6.4 33,000 70% produced in country
Turkmenistan 5.2 27,000 100% produced in country
Uzbekistan 24.8 128,000 35-40% produced in country
40-45% produced in
Total 63.9 330,000 country
15% imported
1
Producers use a practical estimate for production planning of 5kg/capita/year
2. The greatest shortfalls in reported supply are in Uzbekistan (60-65% below estimated
need), Kazakhstan (55%) and Kyrgyz Republic (40%). With the exception of Turkmenistan, not
all the edible salt being sold by producers is in iodized form, however. Only an estimated two-
thirds of all the salt sold for human consumption purposes is supplied as iodized salt in the
countries combined. This proportion varies from one-quarter in Kyrgyz Republic to practically all
the edible salt supplies reported for Turkmenistan and Uzbekistan.
90 Appendix 1
Number of
Iodized salt Use of iodized
local
(% of all edible salt Package sizes salt in
Country producers
supplies) households, %
reported
41
Azerbaijan 5 40 1, 2, 30kg, bulk
MICS, 2000
1kg: 43% 29
Kazakhstan 2 85
50kg: 57% DHS, 1999
0.5, 1, 3 and 5kg: 75%
Kyrgyzstan 3 25 30 (SES data)
50 and 60kg: 25%
1 kg, 3 kg – 30% 20
Tajikistan 3 50
10 kg and more – 70% MICS, 2000
75
Turkmenistan 1 90 (effective) 30 and 40kg
DHS, 2000
75 (SES data)
6
Uzbekistan 95 1, 2 and 50kg 19
(in operation)
MICS, 2000
3. Equipment and machinery for salt harvesting and processing generally date back from
Soviet times and are often >10 years old, except the add-on iodization component donated
through UNICEF or obtained recently from another source (Kyrgyz Republic, Tajikistan). The
iodization method reported most often is continuous wet spraying, but one producer in Tajikistan
reported a dry mixing process. The supply of potassium iodate in Turkmenistan is from the local
Cheleken Company. In all other countries, potassium iodate (from INQUIM S.A., Chile) is
donated through UNICEF, with rare exceptions when it is procured through a Russian dealer
(AralTuz, Kazakhstan) or otherwise (Aga Khan, Tajikistan).
1. Packaging
4. Packaging sizes are variable, from 0.5kg (Kyrgyz Republic) and 1-5kg for retail sales, to
50kg or more in bulk (in Azerbaijan producers also sell salt in loose form). The one factory in
Turkmenistan (Guvlyduz) sells iodized edible salt only in 30kg and 40kg bags, and this salt is
reportedly being re-packaged by retailers before sale. Only the Tajikistan report mentions that
iodized salt is also used in the food processing industry.
5. Iodized salt packaging may be automated (large enterprises) or manual. Packaging
material for small quantities of iodized salt is in polyethylene bags and carton boxes, while large
amounts are packed in polypropylene sacks. The name and location of the producer, type of
salt, expiry date and storage instructions are imprinted on all packs. Not all the producers use a
logo, nor do they all print a recommendation on the use of iodized salt in the household.
2. Quality Assurance and Quality Control
6. Producers in Kazakhstan, Tajikistan, Turkmenistan and Uzbekistan reported the routine
practice of (internal) quality assurance during production to assure that the product complies
with the approved national standard. Test results reportedly are carefully recorded. The iodized
salt produced in Azerbaijan, Kazakhstan and Kyrgyz Republic is subject to (external) quality
control tests by the Sanitary Epidemiological Service (SES), the authorized agency by national
regulations. The Interstate Standard for iodized salt, GOST 13380-97 on “Basic Technical
Conditions” (Minsk, 1997), is in force in all countries. Each country has introduced amendments
of this standard, specifically on iodization level (35 - 40ppm in all countries, except
Turkmenistan where it is 23 ± 11.5ppm), and on the substitution of potassium iodate for
potassium iodide.
Appendix 1 91
7. In Kyrgyz Republic, a Law “On Prevention of Iodine Deficiency Related Diseases”
regulates the production, import and sale of iodized edible salt. The President of the Republic of
Turkmenistan in 1996 signed a Decree on universal salt iodization and on free salt supply for
the poor in the nation. A Decree of the Government of Tajikistan is in force “On the National
Program on Iodine Deficiency Control in the Republic of Tajikistan for 1997-2001”. At the time of
the survey, a similar decree was being prepared in Kazakhstan for proclamation in September
2001. Also in Azerbaijan and Uzbekistan such decrees are under consideration by the
Government. In Kazakhstan and Uzbekistan, the Chief Sanitary Physicians have issued
Decrees on mandatory iodization of table salt and on the control of its quality by the SES.
8. Government authorities in all countries also have proclaimed normative documents that
indirectly deal with the production, regulation, quality control and use of table salt, but as for the
above legal instruments, none of these provide for mandatory iodization of edible salt. Among
the normative documents are laws on the “Protection of User Rights”, “Protection of the Health
of the Population”, “On Quality Control of the Safety of Food Products”, etc. In addition,
governments of all Central Asian countries except Turkmenistan (and Mongolia) have signed a
recent CIS agreement (Minsk, 31 May 2001) on IDD elimination, pledging their collaboration in
joint actions to set improved standards and regulations on the production and cross-border
trade of iodized salt and food products.
9. Quality control of the iodized salt produced, imported and sold is carried out in all
countries by the state food inspection authorities, i.e. the SES networks using the amended
GOST standard, supported by authorized laboratories that use an officially approved iodine
assay. Inspections are mandated at points of production and supplies not less than once per
quarter, and in conformance with formal methods and procedures on the control of quality and
safety of iodized salt. The law in Kyrgyz Republic prescribes this to be done once weekly.
3. Licensing and Pricing
10. All countries by law reserve the right to license the exploration of natural resources,
including salt. The senior government authority in the Oblast where the production enterprise is
located usually controls the license (or contract). The amount of production and sale tax levied
depends on the production volume and on the salt turnover in the wholesale and retail trade.
Any goods or products bought or imported, including iodization equipment and potassium
iodate, are in principle subject to import taxation and customs duty. Producers and trading
companies incorporate the aforementioned taxes into the price of salt charged to their
customers. Salt pricing in the markets is based on free competition among salt traders and shop
owners.
11. The price of iodized salt is affordable for the majority of consumers in all countries. With
few temporary exceptions (e.g. during shortage of supplies), the difference between the price of
iodized and non-iodized salt generally seems not significant.
B. Conclusions
12. The reports of the special SSA surveys indicate significant shortfalls in the supply of
iodized salt in Central Asian countries, varying in size from country to country. Despite the
various legal instruments in force and the official declarations on consumer rights, a sizable
proportion of edible salt produced in the countries is produced and purchased in un-iodized
form. A major part of the gap reported in the surveys between production and demand of
iodized salt most likely is being filled by “technical” salt, i.e. non-iodized salt of the same
composition as edible salt.
92 Appendix 1
13. Most if not all producers possess old technologies, except for the iodization add-on.
Quality assurance systems during production were not reported in detail, and may deserve
improvement. All producers report the use of potassium iodate, and almost all has been
provided for free through UNICEF assistance. The materials used for packaging are adequate
for preserving the quality of the product, especially the iodine content. By and large, the
information imprinted on packaging materials follows the official regulatory requirements.
14. The recent Minsk agreement among CIS countries calls for close collaboration among
governments in improving the legal environment that governs the quality of iodized salt
produced and traded in and among the nations. There is wide variety in decrees presently in
force in participating countries. A law has been passed only in Kyrgyz Republic, but it applies to
edible salt once it is iodized. In all countries, the SES networks are authorized to perform formal
inspections of iodized salt, at production, importation and retail. There is a common product
standard (GOST) which has been amended, as appropriate, by national authorities. The SSA
reports did not provide information about enforcement procedures, nor were any corrective
actions or penalties being reported for non-compliance.
15. The price of the product for consumers in the market does not seem a major factor in
assuring sufficient consumption. None of the countries have a price control in force, and iodized
salt is reportedly provided for free to the poor in Turkmenistan. Any price difference between
iodized and non-iodized edible salt when observed in the markets is not caused by the costs
incurred by producers, but by mark-up by traders or retailers. A temporary shortage of supply
may also play a role in such situations, however.
C. Recommendations
16. Taking advantage of the recent CIS agreement, the legal instruments in all countries to
mandate and enforce universal salt iodization require improvement. The procedures and
methods of (external) quality control by SES networks also deserve strengthening and
harmonization. The reporting of results from inspection, particularly to producers, and their use
for monitoring requires strengthening.
17. The significant supply shortfalls in iodized salt, particularly in Uzbekistan, Kazakhstan
and Kyrgyz Republic, should be addressed. Production processes of iodized salt should be
modernized. Improved cost-effectiveness of established production capacities, and assistance
for newly emerging production facilities both deserve priority attention. In-process quality
assurance, as part of the accepted responsibility by producers, must be routine for all edible
salt. All actors in the market channels must insist on purchasing only iodized salt, including
edible salt traded across borders.
18. The mobilization of producers to become active participants in the oversight of national
IDD elimination policies is a priority for all countries.
Appendix 2 93
JFPR – TA 9005
IMPROVING NUTRITION OF POOR MOTHERS AND CHILDREN
IN ASIAN COUNTRIES IN TRANSITION
A. Additional Guidance on the Design of Country Proposals
1. ADB has shared a guideline on preparing the country proposal and budget, which will be
considered at the Roundtable in Almaty, 4-6 September 2001. The ADB guideline identifies the
five elements to be described in the proposal, and importantly, suggests items that are eligible
for funding under the grant.
2. The present document aims to assist in designing a work plan and selecting specific
activities to be carried out on priority. This document is focused on activities carried out for
achieving and sustaining universal salt iodization. Selection of activities for wheat flour
fortification follows a similar pattern, however.
3. UNICEF provides assistance to Country Working Groups in preparing a first draft of the
country work plan, due by 1 August. Upon receiving comments from ADB and UNICEF on this
first draft, it is hoped that the present guideline will be helpful in preparing the second –hopefully
final- version, due on 22 August.
4. No Russian translation will be provided of this document. PO’s are strongly encouraged
to use the two guidelines in their assistance to the Country Working Group for developing the
best possible country proposals for agreement at the Roundtable.
1. General Considerations
5. Universal salt iodization (USI) has been defined as “iodization of all salt for human and
animal consumption, including the salt used in food processing”. It means “all salt for all people
at all times”. USI is global policy, recommended by UNICEF and WHO as the single most
important strategy for IDD elimination. In all countries where IDD is a public nutrition problem,
governments have agreed upon the policy.
6. On 31 May 2001, governments of the Commonwealth of Independent States signed an
agreement on the prevention of IDD in member states, which asserts their promise to
collaborate in national policy development and implementation, and to undertake concerted
actions and joint decisions in improved legislation, modern food standards, and their
enforcement. The Minsk document fully agrees with the global USI policy.
7. At the UN Special Session on Children to be held in New York, 17-19 September 2001,
government delegations will pledge their support for “strengthened public-private partnerships
for virtual IDD elimination by 2005.”
8. The present ADB-UNICEF project supports the implementation of national USI policies
in the countries included in the project. Supported from the Japanese Fund for Poverty
Alleviation, the project will provide grant money for financing the essential requirements to
achieve the national IDD elimination goals. The grant will enable member states to apply the
Minsk agreement in the shortest time possible.
94 Appendix 2
2. Salt Situation Analysis
9. A SSA was conducted in participating countries, except Mongolia, during July 2001. The
SAA results have been submitted and are being analyzed in the UNICEF Area Office. Direct
communications with PO's on the information is ongoing.
10. The quality of data varies widely among reports and, generally, the sections in the
reports on conclusions and recommendations need improvement. Solid interpretation of the
many data collected will permit the best selection of requirements that are essential for
addressing the obstacles identified in achieving USI.
Key data collection, addressed in the SSA, included:
(i) Iodized salt production,
(ii) Quality assurance (QA) during production,
(iii) Iodized salt packaging and labeling,
(iv) Storage, transport, marketing and pricing of iodized salt,
(v) Inspection of iodized salt and enforcement of standards,
(vi) Licensing, taxation, and
(vii) Access to iodized salt by the consumer.
11. Logically, in each country, the technical constraints to USI that have been assessed in
the SSA fall in these categories. The design elements we suggest below for selection in the
country proposal will follow the same categories as above. In addition to the technical items,
however, each country proposal must address the policy and program management elements
that will make the technical activities work well, and put them in place permanently. These items
include actions that ensure:
(i) Political leadership, and
(ii) National oversight.
Note that project management and administration is part of the overall set-up of the project.
Details are described in the ADB guideline.
3. Selection
12. The following chapters suggest specific items that may be relevant for the ADB project
country proposal. The concern of national development programming is that the problem of lack
of universal consumption must be addressed. The ADB grant provides a way to finance some of
the essential requirements that the national program identifies. Proposing the items for ADB
financing should be accompanied by documentation that the selection will address a key barrier
to achieving and sustaining USI. And that evidence requires intelligent analysis of the data
collected in the SSA.
13. The list of items offered in this guideline cannot be exhaustive. Items other than those
suggested in this guideline may be eligible for expenditure under the present grant. Country
Working Groups are strongly encouraged to submit a complete statement of the national needs,
rather than exclude any requirements because of their perceived ineligibility.
Appendix 2 95
4. Iodized Salt Production
14. National needs for iodized salt can be roughly approximated by assuming that the
consumption of salt in households is 5kg/person/year. For the year 2001, this works out to the
following estimated amounts.
Country Mid 2000 population Estimated need in 2001
(million) (thousands of Tons)
AZE 7.7 40,023
KAZ 14.9 76,926
KIR 4.9 25,508
MON 2.5 12,793
TAJ 6.4 32,985
TUR 5.2 27,112
UZB 24.8 128,133
Total 66.4 343,480
15. In countries where the national supply (production and import) of iodized salt falls
significantly short of needs, reasons for such a shortfall should be addressed. The way this is
done may be a matter of national policy. If existent salt enterprises produce sufficient edible salt
but lack the capacity to iodize all of it, equipment, installation and training in its use would be
needed. The producer(s) should provide assurance that they can sell the new product with a
profit equal to the non-iodized equivalent.
16. Potassium iodate may be provided on the condition that the producer(s) will establish
arrangements with a reputable iodine supply source for future purchases. Packaging equipment
and material may be considered eligible but must be justified.
17. If in a country the installed salt production capacity is not sufficient for the national need,
the project will not provide for new construction. It is encouraged to strengthen systems that
ensure sufficient imports of iodized salt in such cases.
5. Quality Assurance during Production
18. The routine method and procedures applied by salt producers to ensure that the iodine
amounts added to edible salt are always consistent should be strengthened in most countries.
The project may support improved protocols, training of personnel, lab equipment (titration), and
reagent supply (for in-plant testing). In large enterprises, database development and electronic
links (Internet) may be considered. Salaries for QA personnel and lab construction costs are not
eligible.
6. Iodized Salt Packaging and Labeling
19. The project could assist in the development of strategic marketing designs for producers.
The development and registration of a national logo, devising imaginative designs with
promotional information for printing on packaging materials, and design and development of
promotional inserts for retail shops may be considered.
96 Appendix 2
7. Storage, Transport, Marketing and Pricing of Iodized Salt
20. The project may assist producers with improved marketing and promotional efforts, to be
carried out through the salt supply channels. Training may be required for better practices in
storage (for example, first-in-first-out) and improved handling of iodized salt in the wholesale
and retail stages.
21. In many countries an important QA requirement is that Customs should ensure that all
imported edible salt is iodized. Following the Minsk agreement, procedures to enforce
appropriate certificates and specification by foreign suppliers (exporters) of iodized salt must be
improved.
8. Inspection of Iodized Salt and Enforcement of Standards
22. The key condition for improving the access to good iodized salt is to ensure that the salt
is well iodized by producers. Therefore, food inspection in production facilities (and at delivery of
major imports in warehouses) is crucial. The project may support development of better
methods and protocols for inspections, training of SES personnel, procurement of lab
equipment and reagents, improved reporting systems, etc. Modernization of standards of
iodized salt in some countries may be a priority. The project could provide for special studies,
workshops, meetings and publication requirements, for example.
9. Licensing, Taxation
23. As per agreement between ADB and the governments, establishment of tax reforms is a
requirement in all country proposals. The country proposal may consider assistance in business
plan development for individual companies, with explicit justification why the company is
selected to lead the industry in this direction.
10. Access to Iodized Salt by Consumers
24. The proposal in many countries will include plans for verifying that consumers have
increasingly iodized salt in the kitchen store. Household survey design and implementation are
eligible, as well as survey equipment, training of field teams, statistical analysis of data and
reporting requirements.
25. In many countries in this part of the world, consumers may be concerned that iodized
salt affects the preservation of food and vegetables (e.g. pickling). Special studies and
communications efforts may be proposed, to address constraints in consumer demand.
26. A communications strategy is a requirement in all countries. The project may address
various items to strengthen the ongoing efforts in conveying the essential facts of IDD and
information of its resolution to stakeholder groups in society through the channels of
government, industry and grass-root organizations (NGO’s, women federations, civic and
philanthropic organizations, etc). Educational activities in primary schools, as well as insertions
in health curriculums may be proposed. Producers, traders and retailers must sell iodized salt.
Improving their capacity in marketing, advertising and other means of sustaining the demand by
customers may be priority.
Appendix 2 97
11. Political Leadership
27. In the experience of many countries during the last decade, barriers to be overcome
often are political. For example, the question continues to arise whether USI is based on good
and reliable science (despite endorsement by WHO and UNICEF). Another issue is the
suggestion that if salt iodization is universally applied, it could lead to health problems in certain
groups of the population such as the elderly who have suffered long standing iodine deficiency,
or the rich who may already enjoy adequate iodine nutrition.
28. Because USI addresses a threat to national social and economic development (from the
brain damage in each generation of newborns in the country), acceptance of the policy and the
means of its achievement must become elevated and anchored at high political level. The
project may support a National Advocacy Event, to involve all the implementing sectors at
senior levels including the national scientific leadership. The Event is to address and resolve the
national policy issues, and to ensure that USI (and flour fortification) becomes embedded in
broad and high-level political support. The project could finance the costs for developing and
holding the Event, including major publicity in the national media.
12. National Oversight
29. The formation of a multi-sector Country Working Group in the context of the present
grant provides a unique opportunity and experience for collaborative decision making and
blending of the available talents and expertise for national development. Sustaining this
collaborative effort is important because USI must continue after the project ends, to
permanently ensure that the brain damage of iodine deficiency does not return. A group of
highly placed executives from public, private and civic sources may be proposed (a “Country
Watch”). Ways and means for the national oversight function are eligible for funding under the
present project. Meetings, special studies, communications efforts, publicity and advocacy
events could be proposed.
30. Providing permanent national oversight that the progress in IDD elimination endures is
an important element in sustaining the success, once achieved. Another key element to
promote sustainability is that the national community obtains scientific evidence of the benefit of
IDD elimination for the nation during the period that the success is being achieved. Special
studies in early child development may be proposed.
31. Finally, the most important challenge for a Country Watch probably is to oversee that
permanence is assured. When planning to spend foreign assistance for national development, it
is equally important to start planning for independence of foreign grant money. Companies need
to build maintenance and replacement budgets, governments need budgets for training, for
labs, etc.
98 Appendix 3
ALMATY FORUM 2001:
IMPROVING NUTRITION OF POOR WOMEN AND CHILDREN IN CENTRAL ASIA AND
NEIGHBORING COUNTRIES
(Project financed by Government of Japan)
1. After four days of deliberation, participants from six neighboring central Asia nations,
attending a regional roundtable on salt and wheat flour fortification from 8-12 October
sponsored by the Asian Development Bank, the UN Children’s Fund and the KAN and funded
by the Government of Japan through the JFPR, agreed on the following set of principles,
strategies and actions (to be supported by the Japan Fund through 2002):
• We recognize:
(i) In recent years the nutrition status of women and children in our region has
deteriorated badly with negative consequences for children, families and
nations—iodine and iron deficiencies are the most serious, but other essential
nutrients need to be addressed;
(ii) that the damage to the learning capacity of our children from iodine deficiency in
pregnancy is irreversible;
(iii) that iron deficiency is causing serious damage to social and economic
development through poorer pregnancy outcomes, impaired cognition especially
in young children, reduced work capacity and increased morbidity from infectious
diseases;
(iv) that zinc deficiency is associated with lowered immunity, slower growth and
increased risk of heavy metal poisoning in contaminated environments;
(v) that folic acid deficiency in women who become pregnant contributes to
congenital abnormalities of the central nervous system of the newborn and is an
independent risk factor for coronary heart disease; and
(vi) that the key B-vitamins thiamin, riboflavin and niacin are removed during milling
along with most iron and folic acid contributing to micronutrient malnutrition
among populations whose diets are heavily dependent on bread and other flour-
based foods.
• We affirm:
(i) that the addition of potassium iodate to all salt sold for human nutrition is a well
established method for eliminating iodine deficiency as a societal problem;
(ii) that the KAP Komplex formula, developed by the KAN for Central Asia, is an
appropriate and safe basis for wheat flour fortification in the populations of the
region to prevent deficiencies of thiamin, riboflavin, niacin and folic acid and
reduce iron and zinc deficiency. This formula is freely available to any enrichment
mix producer;
(iii) that people of the region should have access to affordable, safe, and efficacious
fortified foods as a permanent commitment to the elimination of micronutrient
malnutrition;
(iv) that there are no capacity constraints for private producers to achieve significant
progress in providing affordable fortified salt and flour to consumers in the region;
(v) that the consequences of not implementing fortification programs at national level
will be poor child development, low educational achievement of children, and
decreased earnings and economic growth; and
Appendix 3 99
(vi) that the initiative, supported by the Japan Fund, will contribute to fulfilling
commitments made by the participating governments to universal protection of
children.
• Therefore, we pledge:
(i) that all salt for human consumption will be fortified with potassium iodate and to
the maximum extent achievable wheat flour will be fortified with micronutrients
using the KAP Komplex formula.
• This will require:
(i) that food laws and regulations be reviewed and amended to ensure they support
and enable the addition of all essential micronutrients in appropriate food
carriers;
(ii) that public policies and regulations that constrain or impede investment in food
fortification to reduce micronutrient malnutrition be reviewed and amended and
that all nations collaborate to produce uniform or consistent standards based on
international best practices that will smooth the trading of foods;
(iii) that customs protocols and trade regulations will be revised or enacted to ensure
the import and export of certified and safe fortified foods at agreed levels of
fortificants;
(iv) that the cost of food fortification must ultimately be borne by the producer and the
consumer, but a transition period of cost -sharing between the public and private
sectors may be necessary;
(v) that efforts be continued to inform the public of the benefits of fortified salt and
flour to the learning and earning capacities of the region's children and that the
interests of NGOs, especially women's federations and consumers' rights unions,
be fully included in future activities jointly conducted by the nations; and
(vi) that food fortification must be a part of a comprehensive strategy of anemia
prevention and control that includes supplementation, dietary diversification,
breastfeeding promotion and other public health measures.
A. National Actions
2. National actions to achieve this will require the following coordinated actions at national,
oblast and local levels:
(i) Pass and effectively implement mandatory salt iodization laws in all countries
and move forward the consideration of flour fortification laws in a timely fashion.
(ii) Urge the elimination of tariffs and value-added taxes on inputs to fortification and
fortified food products, imported or domestically processed, to promote
sustainability.
(iii) Avoid excessive price increases for fortified products that may discourage
consumer preference.
(iv) Initiate cost-sharing by public and private sectors of the costs of producing
fortified salt and flour and strengthen the capacity of the private sector to be fully
self-reliant shortly after the Japan Fund project completion.
(v) Establish a monitoring framework to assess progress in the percent of salt and
wheat flour fortified during production and families with access to fortified food
products.
(vi) Integrate fortification programs into national strategies and policies to reduce
poverty, raise the quality of human resources and support the survival, growth,
psychosocial and cognitive development of all children, especially those of early
ages.
100 Appendix 3
(vii) Promote an expanded public sector-private sector dialogue on fortification of salt
and cereal flour and organize advocacy events to increase program and donor
support.
(viii) Develop and implement a communication strategy and campaign to raise public
awareness and improve the child caring skills of parents on the importance of
fortified salt, wheat flour and wheat flour products and promote increased
consumer demand for these products. These activities will be led by non-
governmental organizations in collaboration with the private sector, national
experts, the media, local authorities and communities.
(ix) Promote mechanisms to exchange information and experiences within and
across the countries of the project using the world wide web and other modern
communication tools.
(x) Obtain, update and disseminate information on the prevalence of micronutrient
deficiencies by including micronutrient-related data collection into Demographic
and Health Surveys, Multiple Indicator Cluster Surveys and other nutrition, health
and education surveys.
B. Regional Actions
(i) Develop a framework for drafting and proposing harmonized regional and
international trade standards and guidelines for fortified foods.
(ii) Develop regional activities such as roundtables, joint reports and cross country
training focusing on legislation, communication strategies and partnerships
among the civil society and private and public sectors.
(iii) Demonstrate through regional policy dialogue to economic planning agencies
and the general public the large economic damage caused by poor nutrition and
the proven low-cost solutions available to the region.
(iv) Advocate resource mobilization by governments from domestic budgets, public
and private, and strategic investments from development partners, and share
country experience in regional forums.
(v) Review and recommend financial and capacity building incentives to sustain food
fortification and its expansion to other essential foods widely consumed by the
poor.
(vi) Set up sentinel sites in at least three project countries to monitor progress of
continuing efforts to fortify all salt and wheat flour.
(vii) Create communication mechanisms, including a web site, that allow project
countries to share advocacy, technical and promotional activities among
themselves and with the global community.
(viii) Include micronutrient malnutrition issues into the agenda of regional expert group
consultations such as associations of pediatricians, nutritionists and reproductive
health specialists.
(ix) Prepare progress reports toward elimination of micronutrient malnutrition to the
Regional Health Ministers Council.
Appendix 4 101
FIRST REGIONAL WORKSHOP OF SALT PRODUCERS OF CENTRAL ASIA:
DECISIONS AND RECOMMENDATIONS
12-13 July 2004, Bishkek, Kyrgyz Republic
1. Heads of salt producing enterprises and the associations of salt producers of the Kyrgyz
Republic, Kazakhstan, Tajikistan and Uzbekistan in the course of two-days discussion of issues
of production and trade of iodized salt of good quality in the countries of Central Asia, conducted
with the support of the Asian Development Bank, UNICEF and the Kazakh Academy for
Nutrition approved the following principles and action platform:
Recognizing that:
• During the recent years due to joint efforts of the governments, civil society and food
enterprises big efforts were undertaken for the organization of production of iodized salt
of good quality, adoption of legislative and normative acts, strengthening of customs and
market control;
• With the support of international organizations and the Japanese Fund for Poverty
Reduction, salt producing enterprises obtained a technical possibility for the production
of iodized salt of good quality and established the system of quality control;
• Governments of countries of Central Asia developed and adopted national programs for
the reduction and elimination of iodine deficiency.
Confirming that:
• Citizens of the region must have an opportunity to receive continuously accessible, safe
and efficient fortified food products for the reduction of micronutrient deficiency;
• Addition of potassium iodate into salt for food preparation and consumption is a tested
method to prevent iodine deficiency as a social problem.
We will assure that:
• All salt, used by humans for consumption will be fortified with potassium iodate;
• The salt producing enterprises and associations of salt producers will undertake
measures for providing iodized salt of good quality at the maximum possible level and
will actively participate in control of quality of salt, which is sold in wholesale and retail
trade;
• Salt producing enterprises will avoid excessive increase in prices for iodized salt , which
might reduce consumer demand;
• Salt producing enterprises will make procurements of potassium iodate at their own
expense after expiration of the assistance from Asian Development Bank;
• Salt producing enterprises and associations of salt producers of Central Asia will
conduct regular meetings-workshops (not less than once per year) for discussing priority
issues and coordination of activities in the region.
For this it is necessary to provide for coordinated implementation of the following actions on
the national and regional levels.
102 Appendix 4
A. Actions on the National Level
• Adopt regulations (normative acts) to strengthen the control of custom, finance, tax and
sanitary bodies over import of non-iodized salt for food and of technical salt;
• Adopt measures to preferential taxation (including VAT) at salt producing enterprises
with the purpose of sustainable follow up after expiration of the assistance from the
Asian Development Bank and successful implementation of the national programs for
reduction of IDD in the region for both imported salt and for the salt produced in the
country;
• Invite associations of salt producers to assist in control of the quality of iodized salt in
wholesale and retail trade;
• Promote broadening of a dialogue between the governmental and private sector on
iodization of salt, organization of informational activities for the dissemination of the
program and broadening of support from donors;
• Develop and implement communications strategies and enlightenment campaigns for
the population of the use and importance of use of fortified food products, including
iodized salt, for food in nutrition of mothers and children, to assist growth of consumer
demand on these products.
B. Actions on the Regional Level
• Attract associations of salt producers to establishment of direct contacts among salt
producers in the region on issues of supply of salt for food and technical salt;
• Attract governments to programs of preferential crediting of salt producing enterprises
for equipping enterprises with modern technological equipment for production of iodized
salt of good quality;
• Attract governments and international organizations to participation in the programs for
equipping salt producing/processing enterprises and controlling bodies with laboratory
and diagnostic equipment (including WYD-checkers and test-indicators), and training of
laboratory personnel on control over quality of iodized salt.
• Attract international organizations, and, first of all, the Asian Development Bank and
UNICEF, towards establishing direct contacts of salt producing/processing enterprises
and associations of salt producers with international suppliers of equipment, potassium
iodate and expendable materials;
• Develop and propose schemes of sustainable independent procurements of potassium
iodate to international organizations;
• Develop such regional activities as round tables, joint reports and joint trainings with the
attraction of specialists from the countries of the region on such directions as legislation,
strategies for dissemination of information and partnership among the civil society,
private and the state sector;
• Promote mechanisms of exchange of information inside countries (domestically) and
among the countries-participants, including web site, which will allow to salt producing
enterprises and associations of salt producers exchange between each other and share
with international community in general the achievements in the sphere of propaganda,
technologies, and formation of consumer demand on iodized salt.
Appendix 5 103
ALMATY FORUM 2004
A. Towards Sustainable Food Fortification in Central Asia, Mongolia and Azerbaijan
1. On the basis of national and regional experience and lessons learned developed during
the first JFPR funded project and current international and regional guidelines and experience
we recognize that:
(i) In many countries of the region the nutrition status of many women and children
continues to be poor with negative health consequences for children, families
and constraining economic and social development,
(ii) Iodine deficiency in pregnancy permanently damages the learning capacity of
children,
(iii) Iron deficiency causes serious damage, through poorer pregnancy outcomes,
permanent impairment of cognition in young children, poor school performance,
reduced work capacity among adults, and increased morbidity from infectious
diseases and increased risk of heavy metal poisoning in contaminated
environments,
(iv) Zinc deficiency is associated with lowered immunity to infectious disease, slower
child growth,
(v) Folic acid deficiency in women, who become pregnant, contributes to congenital
abnormalities of the central nervous system of the newborn and is an
independent risk factor for coronary heart disease,
(vi) The key B-vitamins, thiamin, riboflavin, and niacin are removed from wheat
during flour milling along with most iron and folic acid. This contributes to
micronutrient malnutrition among populations who consume large amounts of
bread and other flour-based foods, and
(vii) Given the seriousness of the health effects of these micronutrient deficiencies,
they must be eliminated as a public health problem.
2. This roundtable strongly reaffirms the goals of appropriate universal fortification of salt
and wheat flours. Recognizing that the progress will vary among countries and between salt and
wheat, it will be necessary to use country specific interim benchmarks to measure progress
toward these goals. Goals and benchmarks are essential and must be used to accelerate
progress toward these goals.
1. Essential National Actions:
3. Each country will:
(i) Complete the legislation and regulations requiring the appropriate universal
fortification of salt and flour in the region,
(ii) Complete the establishment of an effective and high quality system for quality
control and assurance of fortified salt and flour in each country,
(iii) Create conducive conditions for procurement of fortificants and equipment for
fortification,
(iv) Develop an effective national alliance for salt and flour fortification among
government, industry, academia, producers as well as international and bilateral
organizational partners. The alliance will encourage and provide oversight for
implementation of permanent salt and flour fortification,
(v) Encourage regional cooperation, standards, expert advisory services and
mechanisms to facilitate the fortification of salt and wheat flour, share country
104 Appendix 5
knowledge and experience and remove impediments to trade in these
commodities,
(vi) Assure that all salt production facilities and flour millers have the motivation,
commitment and capacity to produce fortified products,
(vii) Assure that the importance of consuming fortified salt and wheat products is
understood at all levels of society,
(viii) Complete a third round of the Sentinel Study in each country to confirm the
impact once fortification is adequately reaching the target population. Additional
funding should be obtained for national micronutrient surveys,
(ix) Ensure imported salt and wheat products meet national standards, and
(x) Look for ways to improve the trade in fortified foods including customs issues.
2. Sustainable Universal Salt Iodization:
a. Expansion/sustainability
(i) The governments will pass harmonized law on salt iodine level in all areas in all
countries in the region,
(ii) The government should allocate sufficient funds in a regular budget line to
activities that maintain universal salt iodization, (e.g. procurement of inputs
allocation for salt tests by food inspectors, allocation to local research for
capturing developmental benefits, public education etc), and
(iii) Salt producers should finance necessary inputs for sustainable production (e.g.
potassium iodate, packaging materials, and promotional efforts).
b. Quality Control and Assurance
(i) Authorized agencies will regularly conduct testing of salt and allocate budget for
the testing in the regular budget,
(ii) The need of countries for the use of establishing mobile iodized salt testing
capabilities should be explored, and
(iii) The regulatory agencies should inform the public the findings from the quality
control tests and industry inspections.
c. Improved regulations
(i) The government should put in place improved trade and tariff regulations to
improve industry’s access to potassium iodate and equipment, and
(ii) The use of the “Healthy Foods” logo should be regulated in terms of the quality of
the products on which it should be used. KAN and UNICEF in cooperation with
the salt and flour producers and government agencies will develop appropriate
guidelines.
d. Shift in demand
(i) The salt producers should conduct more frequent self-initiated promotional
activities about the importance of iodized salt among their customers, and
(ii) Producers should review their customer base to ensure that all customers
serving consumer markets (including food processing industry) actually order
only iodized salt.
Appendix 5 105
3. Sustainable Universal Flour Fortification:
a. Expansion/Sustainability
(i) The association of flourmills should identify the size of mid-sized flour milling
companies to fortify flour, and investigate feasibility and technology of fortification
at small mills,
(ii) The association of flourmills should obtain better information on the production
and consumption of different types of flour and flour products in the region,
(iii) KAN will develop better harmonization guidelines for fortified flour and methods
for systems of quality assurance in the region, and
(iv) KAN will develop new premix formulas for special purposes such as local
commercial production of fortified infant cereals, dilute premixes for small mills,
premix formulas for application at bakeries, and ones that use the more bio-
available ferrous sulfate as the iron source in bakery flour and pasta.
b. Quality Control and Assurance
(i) The association of flour mills in each country, or as a new regional association,
should call upon the Flour Fortification Initiative (FFI) the International
Association of Operative Millers (IAOM) and similar organizations to seek help to
strengthen milling associations in each country and the education they provide,
(ii) Workshop(s) on flour fortification quality assurance and control will be conducted
with assistance from the Centers for Disease Control and Prevention,
(iii) The governments milling associations and individual producers should enforce
flour labeling,
(iv) The National Fortification Alliance in each country should give incentives for
flourmills to produce quality fortified flour (e.g. award for excellence),
(v) Regulatory agencies will regularly conduct testing of fortified flour. This requires
sufficient budget allocation for the testing in the regular budget,
(vi) SES should report the findings from the test and industry inspections to the
public, and
(vii) Flourmills should be encouraged to periodically send samples of fortified flour to
the KAN for analysis in relation to compliance with recommended levels of
micronutrients and KAN should provide feedback to national authorities in all
countries on a timely manner.
c. Improved Regulations
The government should:
(i) Require that imported 1st and premium grade flour be fortified to national
standards,
(ii) Remove any legal barriers to production, sale and promotion of fortified bread or
other baked products made from fortified flour, and
(iii) Achieve regulations for universal flour fortification of 1st and premium grade flour
in each country.
d. Shift in demand
(i) The government and flour mills should promote purchase of fortified flour by
bakers and flour distributors, and
106 Appendix 5
(ii) The government and flour mills should continue promotion and education of
general public on why they should look for flour and bread with “healthy foods”
logo.
B. Effective Communication and Advocacy:
(i) Food producers, civil society, and NGOs should continue working on advocacy,
for example, to convince the government to allow producers to access foreign
currency to buy flour premix, to convince foreign donors of wheat to provide
premix, to convince the government to require that imported wheat flour and salt
be fortified and to establish regulations to allow multiple premixes for additional
special uses, with support of the KAN and premix manufacturers,
(ii) Bakers and other organizations producing products using flour and salt should
become full partners in fortification efforts and will be convinced of the efficacy of
fortified bread,
(iii) The government and the communication group should assure that modules on
micronutrient nutrition, including IDD, IDA, Vitamin A, and folic acid deficiency
become well established and a regular part of both pre-service and in-service
training for health professionals, teachers and a topic of regular orientation for
key media staff,
(iv) The appropriate government agencies should better inform communication
groups including non governmental organizations (NGOs) concerning technical
standards and recommendations related to flour and salt fortification and related
nutrition issues,
(v) The government, private sector, and NGOs should include ongoing monitoring
and adjustments of communication activities to refine communication strategies
to convey mutually reinforcing messages, and take into account needs of
particular geographical areas or groups,
(vi) Groups working on communication including NGOs should translate useful
reports and information, including vitamin and mineral deficiency country damage
assessment reports, as advocacy source for generating interest of the media and
government in fortification and better micronutrient nutrition,
(vii) Development agencies and projects, including the JFPR Project, UNICEF and
international NGOs, working with communication groups of the country projects,
with support of KAN, will organize and share all materials used for orientation
and education of professionals in education, health, and other areas by
JFPR9005 and others, and share findings and recommendations among the
countries and at regional levels,
(viii) The CPOs in collaboration with UNICEF will support capacity building of NGOs in
areas related to demand generation for promoting fortified wheat flour and
iodized salt,
(ix) The communication activities of each country project should be better linked to
related activities in health, education and nutrition (including GAIN), and
(x) The communication activities should be well coordinated in terms of timing and
linkage with activities related to the supply of fortified flour and salt.
C. Monitoring and Evaluation:
(i) Appropriate national organizations and institutes, and international organizations
will further collaborate in the development of monitoring mechanisms related to
the effectiveness of major project activities to provide guidance and facilitate
Appendix 5 107
improvements that lead to achieving the goals of universal salt fortification and
fortified wheat flour,
(ii) The KAN will develop an overall model and provide technical guidance for all
countries supporting implementing sentinel studies and, at an appropriate time,
country-wide surveys to determine national effectiveness of universal salt
iodization and widespread use of fortified wheat flour on the health of the
populations. Surveys on USI need to be completed before the end of 2005 in
order to allow monitoring of country achievements of the targets set in the US
Special Session on Children (“A World Fit for Children”),
(iii) There should be operational linkage of the project efforts with National Nutrition
Surveys and other relevant population surveys,
(iv) The research community will collect indicators to supplement urinary iodine that
relate to the demonstration of developmental benefit(s) in the population of
improved iodine nutrition status, and
(v) NGOs and civil society should encourage citizen based monitoring activities to
identify how the target group is benefiting.
108 Appendix 6
SECOND REGIONAL MEETING OF SALT PRODUCERS:
QUALITY SALT IODIZATION IN CENTRAL ASIA AND MONGOLIA
22–24 November 2005, Tashkent, Uzbekistan
A. Decisions and Recommendations
1. Representatives from salt production companies and the salt producer associations of
the Kazakhstan, Kyrgyz Republic, Mongolia, Tajikistan and Uzbekistan, having discussed the
progress already made and the remaining urgency to reach sustainable quality salt iodization in
Central Asia and Mongolia in the course of three-day meeting conducted with the support of the
Asian Development Bank, UN Children Fund and Kazakhstan Academy for Nutrition approved
the following principles and recommended actions:
Confirming that:
2. Since holding the First Meeting of Salt Producers of Central Asia less than one year ago
(12–13 July 2004, Bishkek, Kyrgyz Republic), a significant amount of progress has been made
in increasing the production, sales and consumption of quality iodized salt in the countries of
Central Asia, guided by the adoption and implementation of appropriate legal frameworks and
collaborative arrangements where available;
Recognizing that:
3. Government decisions on legislation, national programs and food fortification alliances
have been effectuated in all countries. Similarly, in all countries progress has been made in
formulating official regulations and guidelines on monitoring and quality control of the
production, sales and storage of iodized salt for human consumption. Salt producer associations
have been created in Mongolia and Kazakhstan.
4. Compared to 1999–2000, the consumption of iodized salt in households has increased
to the following status by 2005 4 : Kazakhstan: from 29% to 83%, Kyrgyzstan: from 30% to 41%,
Mongolia: from 43% to 57%, Tajikistan: from 20% to 28%, Uzbekistan: from 19% to 56%.
5. Salt producers from the Kazakhstan and the Kyrgyz Republic have started procurement
of the potassium iodate from their own funds; UNICEF provided the initial support for the
procurement programs in Mongolia, Tajikistan and Uzbekistan.
6. Salt producers associations in partnership with the consumers' federations and other
participating non-governmental organizations and with support by ADB and UNICEF launched
monitoring of the quality of iodized salt and its wholesale and retail prices.
Recalling that:
7. Along with this outstanding progress, a number of challenges remain. Legislation has yet
to be enacted in Uzbekistan. In all countries, difficulties continue in the procurement of
potassium iodate, in ensured quality control, regulating value-added taxes and customs tariffs,
and import and sales of uncertified, non-iodized salt, which substantially impede the increase of
the production and sales of quality iodized salt.
4
The data reflect the UNICEF sources, as UNICEF was authorized by the world community on IDD/USI data
Appendix 6 109
8. The following efforts are of key importance in each country to realize the USI goal:
(i) Periodic renewal of political will and commitment,
(ii) Continuous development of the capacity in the salt industry for quality iodized
salt production and supply,
(iii) Transparent enforcement of legislative acts and appropriate regulations to guide
national programs, and
(iv) Monitoring of salt iodization efforts and surveillance of iodine nutrition in the
population.
Based on the international and regional experience and progress to date, the participants in this
meeting reconfirm their support to the goal of universal salt iodization (USI) in order to protect
newborns from brain damage and reduce national economic loss. Reaching this goal will make
a sizable contribution to the realization of the agreed-upon MDG and assist in an important way
to poverty reduction in Central Asian countries. The salt producers of Central Asia, individually
and through their national Salt Producer Associations, are ready to assist in ensuring these
efforts on priority. Therefore, they resolve to undertake the following actions:
1. Upholding the principle that salt production companies are responsible for
achieving through USI by ensuring:
(i) Ongoing improvements in quality iodized salt production,
(ii) Promotion of iodized salt to the customers and the public, and
(iii) Un-interrupted adequate potassium iodate supplies by requesting UNICEF
assistance where appropriate.
2. Strengthen the authority of the Salt Producer Associations in its collaboration as
a full partner in national salt iodization programs in each country by:
(i) Promoting membership by all salt production companies in the country,
(ii) Membership of the Chairperson in the national food fortification alliances, and
(iii) Engagement by the Association as a full participant in the processes of
regulation/legislation.
3. Strengthen the collaboration of Salt Producer Associations with the Government
and other country partners by:
(i) Facilitation of cross-border trade and reduction of transport costs, tariffs and
value-add taxes,
(ii) Improving of border control against illegal imports and exports of non-iodized
salt,
(iii) Continuous improvements of quality monitoring systems, and
(iv) Regular reports to the Food Fortification Alliance about the status of iodized salt
supplies and submit proposals on how to improve the supply.
110 Appendix 7
ALMATY FORUM 2007
A. Towards Sustainable Food Fortification in Central Asia and Mongolia
1. Draft for Discussion
1. In 2001, four Central Asian countries (Kazakhstan, Kyrgyz Republic, Tajikistan and
Uzbekistan) and Mongolia embarked on a set of ambitious national goals to ensure access to
affordable, safe and efficacious fortified food as a permanent commitment to eliminate
micronutrient deficiencies in their populations, and the Asian Development Bank, the UN
Children’s Fund and the KAN, funded by the Government of Japan through the JFPR started
close collaboration in support of these goals.
2. At the Almaty Forum 2001, multi-sector delegations led by high-level ministerial officials
promised to work together to fortify all the salt for human consumption with potassium iodate
and fortify wheat flour to the maximum achievable extent with micronutrients using the KAP
complex formula. A regional roundtable reviewed the progress being made toward these
pledges at the Almaty Forum 2004 and agreed to a detailed work plan to tackle the immediate
shortfalls. In recognition that universal salt iodization and mandatory flour fortification contribute
to sustainable elimination of micronutrient deficiencies, multi-sector delegations from the
participating countries have once again gathered at the Almaty Forum 2007 to take stock of the
achievements, to analyze the challenges that are still remaining, and pledge to complete the
national fortification agendas.
3. Significant progress has been made in increasing the production, sales and consumption
of quality iodized salt guided by the adoption and implementation of appropriate legal
frameworks. Flour fortification also has been steadily expanding, but still lacks legal and
regulatory frameworks to provide a level playing field for all mills.
4. On the basis of national and regional experience and lessons learned during the last six
years we recognize that:
(i) In many countries of the region, the nutrition status of many women and children
continues to be poor with negative health consequences for children, families and
constraining economic and social development,
(ii) Iodine deficiency in pregnancy permanently damages the learning capacity of children,
(iii) Iron deficiency causes serious damages including poorer pregnancy outcomes,
permanent impairment of cognition in early childhood, poor school performance of
children and teenagers, reduced work capacity among adults, increased morbidity from
infectious diseases and increased risk of heavy metal poisoning in contaminated
environments,
(iv) Zinc deficiency is associated with lowered immunity to infectious disease, and slower
child growth,
(v) Folic acid deficiency in women who become pregnant contributes to congenital
abnormalities of the central nervous system of the newborn and is an independent risk
factor for coronary heart disease,
Appendix 7 111
(vi) The key B-vitamins thiamin, riboflavin, and niacin are removed from wheat during flour
milling along with most iron and folic acid. This contributes to micronutrient malnutrition
among populations who consume large amounts of bread and other flour-based foods,
(vii) Given the seriousness of the health effects of these micronutrient deficiencies, they must
be eliminated as a public health problem,
(viii) This roundtable strongly reaffirms the goals of appropriate universal fortification of salt
and wheat flours, and
(ix) Recognizing that the progress will vary among countries and between salt and wheat, it
will be necessary to use country specific interim benchmarks to measure progress
toward these goals. Goals and benchmarks are essential and must be used to
accelerate progress toward these goals.
B. Essential Recommended Actions at the National Level
(i) All countries will anchor food fortification strategies as an integral part of their national
development plans and national budget to ensure sustained commitment at the highest
political level,
(ii) All countries will strengthen an effective national alliance for salt and flour fortification
among government, industry, academia, and producers,
(iii) All countries will complete the legislation and regulations requiring flour fortification,
(iv) The Kyrgyz Republic, Tajikistan, and Uzbekistan will complete the establishment of an
effective and high quality system for quality control and assurance of fortified salt and
flour,
(v) All countries will ensure that imported fortified foods meet national standards,
(vi) All countries will remove barriers to procurement of fortificants and equipment for
fortification, recognizing the achievements in Kazakhstan and the Kyrgyz Republic,
(vii) All countries will assure that the importance and safety of consuming fortified salt and
wheat products is understood at all levels of society,
(viii) All countries will continue to strengthen inter-country collaboration through existing
mechanisms of communication to make optimal use of expertise and experience,
harmonize standards, strengthen quality assurance, remove impediments to trade in
fortified foods and create economy of scale for food fortification inputs such as premix,
(ix) All countries will ensure regular meetings to report on progress and renew political
commitments to the food fortification goals,
(x) All countries will establish a national fortified food surveillance system and report on
fortified food supply, consumption and biological outcomes, and
(xi) Governments and parliaments should set aside adequate funds in their central budgets to
finance activities required for sustaining universal salt iodization and flour fortification.
