- Arnold Timmer — Nutrition Specialist, UNICEF
- Cari Tuna — Co-Founder, Good Ventures
- Elie Hassenfeld — Co-Executive Director, GiveWell
This set of notes gives an overview of the major points made by Arnold Timmer.
UNICEF has a long history of working on salt iodization. The World Summit for Children in 1990 put the issue of iodine deficiency on the agenda for governments. At that time only 20% of the households in the developing world were using iodized salt. UNICEF partnered with Kiwanis International to increase the prevalence of salt iodization. Kiwanis has been one of the main supporters of fundraising for salt iodization. Aside from Kiwanis, some other major funders of salt iodization are USAID, the Gates Foundation and Canada’s Micronutrient Initiative.
Getting a country to iodize all edible salt requires national policies. UNICEF has worked hard to get countries to mandate salt iodization for human and animal consumption. UNICEF also put effort into working with the salt industry to increase iodization and to build the trust between the public, private and civil society sectors. Furthermore, communication and monitoring received a lot of attention. By now, salt iodization coverage has increased to ~ 70%.
Over the last few years there has been some stagnation in the global average, but the number of countries using iodized salt has increased. Around 90-100 countries report on salt iodization. Also, every three years countries have to report back to the WHO on the status of iodine deficiency elimination (through the World Health Assembly).
UNICEF’s salt iodization efforts currently focus on two things. One is getting salt iodization scaled up in countries that they call “make or break” countries. The other thing that UNICEF works on is sustainability. Some countries that have achieved success have slid backwards and the use of iodized salt has dropped. UNICEF wants to establish sustainability mechanisms.
To reach the remaining 30% of households, focus has shifted to scale up USI in about 16 make or break countries. The situation in these countries is exceptional and different approaches have to be found. UNICEF and GAIN are working together in a partnership to increase iodization. The Gates Foundation-funded program supports salt iodization in 13 “make or break” countries. If these countries were all to obtain 90% iodized salt coverage then the worldwide coverage rate would increase from 70% to 85%. The funding from the Gates Foundation covers activities from 2008 to 2015. Funds from the Gates Foundation largely cover UNICEF and GAIN funding needs in the 13 “make or break” countries through 2015.
In terms of sustainability, support now focuses on establishing national ownership, a good coordination mechanism, building public-private trust and providing support that will be sustained. For example, UNICEF originally supported hardware and supplies to the salt industry to iodize salt. Now, the focus in UNICEF has shifted to working with stakeholders in the countries to ensure iodization is sustainable through cost recovery mechanisms.
UNICEF is focusing on developing countries. However, there are also countries in the developed world that have not eliminated iodine deficiency, in particular the UK, Italy and Belgium. Where possible, UNICEF does do some advocacy in developed countries.
Funding opportunities in Gates Foundation focus countries
There may be room for more funding to set up revolving funds for potassium iodate in Ethiopia and Pakistan. Funds allocated to this may not be sufficient.
Sudan has a very low salt iodization rate of 2% and is a make or break country. Funding support for Sudan could not be generated and therefore efforts required to scale up cannot be implemented. The low salt iodization rate in Sudan is largely the result of the complexity of the problem with salt producing states without a severe iodine deficiency problem that may not necessarily see the importance of (mandating) iodizing salt.
Madagascar and Angola
Madagascar is another country where sustainable iodization of salt has not been achieved. However, also here a funding gap exists. The same is true for Angola.
Eastern Europe and Central Asia
Countries in Eastern Europe and Central Asia have been neglected. Salt iodization coverage for the whole of Eastern Europe and Central Asia went from 21% to 55% in 6 years time but there are still major gaps. Some countries that were successful at implementing salt iodization are Belarus, Bulgaria, Romania, Croatia, Serbia, Macedonia, Montenegro, Georgia, Kazakhstan, Turkmenistan and Armenia. Other countries such as Tajikistan, Uzbekistan, Kygyzstan and Azerbaijan have not yet established successful programs. Salt iodization in the latter countries could be attained with a relatively small investment because the general resources and infrastructure are available and the limiting factor is technical support, advocacy and communication. Turkey has a large population size and with a small amount of resources could move to better coverage (from 70% to 90%).
In Tajikistan and Kygyzstan, salt is being iodized but the quality of the iodization is not so good.
Many countries have many small producers of salt. The small producers can’t realistically iodize salt themselves. Perhaps it’s possible for the businesses that buy salt from producers and sell salt to consumers to iodize the salt.
A common problem is a lack of trust between governments and the private sector. Mr. Timmer believes that this can be overcome with high probability. Often the problem arises from misunderstanding can be overcome with an opportunity for the parties to sit and talk with each other and create understanding of each other’s interests. UNICEF facilitates this process and builds trust.
Other potential funders for the above countries
It’s hard to find donors who are interested in funding programs in Eastern Europe and Central Asia. UNICEF’s offices in those countries are small with limited resources. Many donors are interested in Sub-Saharan Africa and South East Asia because mortality and nutrition indicators are worse there. There’s an assumption among donors that because Eastern European countries are transitioning they’ll be fine.
Each UNICEF country office gets basic resources depending on the number of children living in a country, mortality rates in the country and the income of the country. Some of this money can be used for iodine, but it’s very limited. Without external funding there’s no significant shift in salt iodization in the countries mentioned. They have not received funding for 4-5 years and there’s been no large change in their situation.
UNICEF has unsuccessfully tried to seek funding for funding for salt iodization programs in Eastern Europe and Central Asia. A funding gap still exists.
Other questions GiveWell asked Mr. Timmer
GiveWell asked Mr. Timmer how he views the odds of success in the countries discussed, assuming that funding comes through. He said that with funding, prospects for increasing salt iodization would be very good. This is belief based in part on knowledge of dramatic past successes in Georgia and Armenia. Mr. Timmer believes that with funding seven of the ~ 10 countries that he mentioned would undergo a change within five years.
Mr. Timmer guesses that the amount of funding that would be needed to promote salt iodization in the countries mentioned is in around $200,000-$300,000 per country.
GiveWell asked about UNICEF's process for monitoring improvements in iodization.
UNICEF’s monitoring consists of national surveys that measure the iodine levels in salt in households. There’s a database giving levels of coverage at the date indicated at www.childinfo.org. The surveys don’t occur every year; they occur every three to five years. If one wanted to do a survey immediately after a particular project to gauge its effect some part of the project budget would need to be allocated to the survey, at a cost of approximately $100,000.
Non-iodization nutrition programs
UNICEF supports many nutrition programs, and Mr. Timmer believes that for many nutrition programs, funding is the bottleneck to progress. UNICEF’s focus is on addressing chronic undernutrition (stunting and micronutrient deficiencies) as well as acute malnutrition through programs such as:
- Micronutrient powders (aka Sprinkles) for the improvement of the quality of the food of children 6 to 23 months.
- Infant and young child feeding, including behavior change around nutrition (e.g. complementary feeding) which is huge and uncovered. It takes a lot of effort to establish a change and so is not attractive to donors.
- Vitamin A supplementation, which is similar to immunization in that the current challenge is reaching the last mile, which requires a different approach. There’s also a need for advocacy to make sure that funding for vitamin A is included in national budgets so that countries become less dependent on outside resources.
- Supplementation for pregnant women (which has low coverage rates).
- Scaling up management of acute malnutrition.
- Food fortification other than salt iodization.
- Nutrition and HIV
We did not have a chance to discuss these in depth on our call.