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| Current IDD Situation |
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| Salt Situation Analisys |
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| USI Program |
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| Other Interventions |
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| Key Lessons Learnt |
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| Challenges |
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| Future Plans |
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| Indonesia |
| Country Profiles > Indonesia |
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Current Iodine Deficiency Disorder Situation Population Population: 219.883 millions
About 13% of the households consumed salt with inadequate iodine levels, and around 14% of all households consume salt without any iodine. Household coverage of iodized salt varies among provinces, from 31.4% in Nusa Tenggara Barat to 98% in Papua, with relatively lower coverage coinciding in the salt-producing regions. The recent national survey supported by the World Bank showed that the median urinary iodine concentration was 229 m g/L in 2003 (MOH, 2004).
Production The challenges to achieve Universal Salt Iodization (USI) are partly reflected in the way the salt industry is organized. The industry is comprised of approximately 20,000 salt farmers and almost 400 producers catering to a population spread throughout approximately 13,000 islands, thus causing difficulties in controlling the flow and quality of salt. For the current year 2003, MOIT estimates the demand for household salt to be 700,000MT, of which 500,000MT (or 71 percent) is produced domestically. Salt is produced by method of seawater evaporation, and production is concentrated in Java Island, Madura, South Sulawesi, and West Nusa Tenggara. The state owned PT Garam produces 20 percent of the country's salt and more than 20,000 small salt farmers produce the remaining 80 percent. The salt fields are operated by subsistence farmers and usually offer lower returns than agriculture and even unskilled labour. Small farmers usually sell their salt to traders who in turn sell it to salt processors that wash, dry, iodize and pack the salt. However, about 20% of the crude unprocessed salt finds its way into the market and the consumer. The salt processors vary in size from small, medium to large. There are 376 processing units of which 11 accounting for half of the total production and most of that salt produced in these units is adequately iodized. While the larger units are well organized the smaller enterprises lack financial and technical resources and their compliance with the iodization requirement is variable resulting in the 15-20% of inadequately iodized salt. Most of the larger enterprises are also known to also import salt when local salt is unavailable or of poor quality. Since 1998 Indonesia has been importing salt, largely from Australia and India, to fulfill demand that cannot be met by domestic production. MOIT determines the level of salt to be imported based on forecast of domestic salt production, stock position of licensed importers and expected demand. The imported salt is for the most part intended for industrial or food processing purposes, but some is processed for household consumption.
Iodine Procurement and Utilization
Universal Salt Iodization Program Information, Education, Communication (IEC) Activities
Social Enforcement Social enforcement strategies were developed by Ministry of Health in coordination with other related stakeholders as an alternative means to increase compliance with iodized salt regulations in the absence of an effective legal environment. Reports from provinces and districts revealed that the social enforcement activities had increased the community awareness and participation to support the IDD control program. There were many diverse approaches to social enforcement once the districts were allowed to pursue the enforcement means most suited to local conditions. For example, several districts involved the local chapters of the National Women's Organization (PKK) in assisting iodized salt distribution through the creation of alternative iodized-salt only markets in districts in four provinces (NTB, NTT, Central Java and South Sulawesi). Rembang district also established certified village salt vendors. Other districts, such as Agam district, encouraged the participation of local community and religious leaders in promoting iodized salt consumption as well as the participation of local market officials in monitoring and prohibiting non-iodized salt distribution in the markets. Successful social enforcement strategies were disseminated and implemented across provinces and IIDC grant (WB funded project) districts through advocacy workshops with local government officials, parliamentarians, non government organizations, and civil society. Legislation The current government approach to the industry is expressed through Kepres 69/1994 which emphasizes the processes which must be used to process salt. Although the emphasis is on process, there are also specifications for salt quality and iodization levels. The salt quality specifications are higher than are currently produced by many processors, again giving advantage to the biggest processors and the government owned company. This effect is compounded by the low quality of salt produced by the farmers/sharefarmers. Meeting the requirements for processed salt under the Kepres will require multiple washing of most of the salt produced. Under these new regulations, the MOIT licenses processors on the recommendation of the provincial office of the MOIT. Legislation and regulations allowing for cancellation of licenses after 3 warning letters are in place and MOIT has notified the industry of its intention to enforce these in conjunction with the newly issued licenses.MOIT set national standard for iodized salt (SNI) in 1995 and revised the standard in 1998 and 2000. The present version prescribes 94.7% sodium chloride and a minimum of 30ppm iodine, to be added as potassium iodate. Since issuing the SNI, monitoring and enforcement of the 376 licensed industries remains weak. MOIT inspection acknowledges that only 236 salt producers meet the national standard. The most important draw back in the implementation of SNI is that there is no budget allocated to any unit of the government to enforce USI, neither at the wholesale/retail level, nor in imported salt. The Food and Drugs Control Board inspects salt in markets, but does not have authority to prohibit the sale of non-iodized salt. As such, non-compliance to the national standard does not result in any legal repercussions or remedial action. Since decentralization policy took effect in January 2001, USI efforts have been shifted to the district level, where the legislative authority and enforcement now lie. Numerous districts have developed their local legislation, but enforcement still needs to be improved. Unlike the central-level policies, the district legislation focuses on the prohibition of non-iodized salt as opposed to the quality of iodized salt. Though considerable efforts have been made through schools and mass media campaigns, consumer awareness on the benefits of iodized salt remains low in many areas of Indonesia, particularly in the eastern part where much of the sea salt is produced. Perhaps this indicates oversupply or economic advantage of purchasing non-iodized salt.
Program Monitoring and Evaluation Responsibility for salt industry as a whole rests with the MOIT which, in reality, concentrates on processors and processing in its relations with the industry. Monitoring the levels of iodine in salt is split between the MOIT, the MOH and National Agency for Food and Drug Control (NADFC). Ministry of Health monitors the iodized salt consumption through the SUSENAS (national Socio-economic survey by Central Bureau of Statistics), MOIT monitors salt iodization at the production level and NADFC at the market/distribution level. Neither ministry has adequate resources to this effort, the number of samples collected and analyzed is somehow too small, and the lack of links between the various data sets make it difficult to identify the processor responsible for any sub-standard samples. There has been limited attempt at enforcement of regulations even when salt samples are shown to contain inadequate levels of iodine.The problem of legal enforcement is especially difficult in salt-producing areas. The supply of raw salt is abundant, and the large numbers of farmers, traders and producers involved make monitoring and control more difficult. National Coordination Indonesia has historically been at the forefront of the global movement to eliminate iodine deficiency. It was one of the leading nations at the Policy Conference on Hidden Hunger in 1991 that presented a comprehensive national strategy for IDD control, based on supplying high quality iodized salt and targeted distribution of iodized oil in affected high-risk areas. This multi-pronged strategy is jointly implemented by Ministry of Health (MOH), Ministry of Industry & Trade (MOIT), National Board for Food and Drug Control Board (NBFDC), and Ministry of Home Affairs (MOHA). UNICEF has long experience in control of IDD in Indonesia. It has provided support to the GOI for control of IDD for 20 years, originally by donating iodization equipment and iodate, then iodized oil. In recent years UNICEF has worked with MOIT to improve iodization of salt, through improved salt monitoring, marketing campaigns, and community-based efforts using school teachers. The World Bank supported Government of Indonesia in eliminating iodine deficiency through an Intensified Iodine Deficiency Control Project (IIDCP; 1997-2003; project size USD 18.8 million). The objective of the project was to reduce the prevalence of iodine deficiency through: (a) monitoring the iodine status of the community, (b) increasing consumption of iodized salt; (c) increasing the supply of iodized salt; (d) targeted distribution of capsules; and (e) improved coordination of activities between ministries and with the private sectorA national IDD coalition has been informally established through supported of the IIDC project. The coalition is consisted of all stakeholders in the country i.e. MOH, MOIT, MOHA, Association of Salt Producer, UNICEF and WB.
Targeted distribution of iodized capsules The distribution of iodized capsules (iodized peanut oil, Yodiol) was initiated in 1992, and until 1999 procurement of the capsules was centrally managed. The challenges of the iodized capsules distribution was after the decentralization in which the responsibility of capsule procurement and distribution transferred to the local governments. Many local governments did not make this activity a priority and indeed many even failed to report procurement and distribution information to the central Ministry of Health. The recent survey conducted by Intensified Iodine Deficiency Project (funded by the WB), the coverage of iodized oil capsules for women of child bearing age in moderate and severely endemic areas reached only 33% in 2003 and for children in severely endemic areas, only 48% received capsules. There was also wide geographic variation in coverage- Maluku only correctly targeted 5% of women of child bearing age (again, surely the local conflict in Maluku played a role). On the other hand, concerted efforts were made to improve capsule targeting in the IDD block grant districts where coverage reached 46% for women of child bearing age and more than 80% for children. Clearly the more focused approach and oversight of the district block grant program significantly improved the performance of this component in those localities. Many factors contributed to the low overall coverage of capsule distribution such as (i) lack of a monitoring system at some critical points of iodized oil capsule distribution, (ii) barriers and constraints in supply and distribution of iodized oil capsules, (iii) lack of local information for appropriate target groups and locations, and (iv) limited follow up of the national government, especially given the amount of government funds involved.
Key Lessons Learned Salt production should be streamlined to improve the quality of raw salt, ensure transfer and effective iodization at the iodization plants and monitoring of salt at processing and consumption levels. In those districts where salt production is a significant source of income, special effort must be undertaken to ensure that three essential components work together at district level: information, communication and strategy implementation. In addition, the leakage of non-iodized salt from traders to markets and distribution of KIO3 should be addressed. Communication encompasses all the efforts to generate political support and fund allocation at district level, as well as to strengthening broad acceptance of iodized salt by the public through health education and product promotion. Information obtained from monitoring and observation should be used by district leadership to make informed decisions on assuring permanent progress toward IDD elimination.
The difference in price between iodized and uniodized salt is a critical factor influencing the demand for iodized salt. There are no systematic surveys of the price differences across the country but in general iodized salt is 2-3 times the price of uniodized salt. The price difference is driven by the availability of low quality raw salt, the high cost of processing a low quality product, and the costs of iodization and packaging. Compared to the costs of processing and packaging, those for iodization are small. In addition, as part of the effort to improve the supply of iodized salt, one province has given monopoly rights for iodized salt to PT Garam. While the supply of iodized salt has improved, the price is high due to lack of competition. Monitoring the iodine content of salt is inadequate and regulations mandating iodization of salt for human consumption are seldom enforced. Although responsibility for monitoring and enforcement rests with both the MOIT and the MOH, the ability to enforce regulations via cancellation of licenses lies with the MOIT. Resources for monitoring in both ministries have been inadequate and are threatened by a projected lack of resources. NADFC has only a limited budget to continue salt monitoring at the market level after project ends - they estimate they will only be able to monitor at 10-20% of the level witnessed under the IIDC project. For monitoring and other efforts, NADFC and MOIT are exploring the establishment of a direct linkage to continue enforcement efforts and information sharing. These linkages in general are likely to be effective in a decentralized context, especially if the linkages are made at the province level MOIT and NADFC offices, since local governments are more likely to respond to joint teams. The recent decentralization of authority to districts and regional creates a major ch allenge for ID control planning, priority setting, and implementation is the need to respond to marked differences between districts in the dimensions and features of the problem. For instance, districts vary as regards the importance of the salt industry, salt infrastructure and expertise, cultural practices related to salt farming, and the extent and awareness of the IDD problem. Future Plans for Sustained IDD Elimination In line with the global goals, the GOI has adopted the goal of Universal Salt Iodization by 2005. The GOI will continue to strengthen multi-sectoral collaboration among several Government Departments: Health, Industry and Trade, Home Affairs, Education, Family Welfare and Food and Drug Control Board. For future plans, the needs to ensure USI are: • Ensuring that un-iodized salt does not enter the market either directly from the salt fields or from imported sources, by strengthening the monitoring and enforcement of regulations at processing and importation and market levels. • Ensuring that iodine content in the salt is within the acceptable range both at point of processing and at the time of consumption. • Ensuring that ongoing efforts are sustained and supported with a coordinated strategy involving all key sectors and stakeholders. • Ensuring adequate supply of potassium iodate ia key requirement to increase salt iodization. • Ensure strong advocacy for political commitment and demand creation The Government of Indonesia has prepared a comprehensive exit strategy of the IIDC project which is now called National Action Plan for Elimination of Iodine Deficiency . The strategy plan was formulated by a inter-ministerial team, health and nutrition related NGOs, and academia. These consultations resulted in a document that will be disseminated to province and district governments as a reference for planning and management for IDD control. The resulting National Plan of Action on IDD Control is categorized by 8 general types of interventions. However the exact mix of policy options recommended to a particular district depends on three important district characteristics: (i) whether the district is classified as endemic or not, (ii) whether the district is a salt production area or not, and (iii) whether or not district residents consume adequate amount of iodized salt. The 8 types of interventions are recommended to be applied in different combinations for each type of region. The eight intervention types generally concern: a) strengthening commitment of local government, b) increasing raw salt production, c) increasing supply of iodized salt, d) social and law enforcement, e) monitoring the quality of salt, f) institutional strengthening, g) increasing coverage of iodine capsule distribution and h) monitoring and evaluation of IDD Control Program.
Sources: Central Bureau of Statistics, Ministry of Health and the World Bank. National Household Salt Consumption Survey. SUSENAS. 2003 BAPPENAS (National Board for Planning), Ministry of Health, Ministry of Industry and National Board for Food and Drugs Control (POM). National Plan for Elimination of Iodine Deficiency. 2005 World Bank. Indonesia: Intensified Iodine Deficiency Control Project, Implementation Completion Report, 2004 World Bank. Indonesia: Intensified Iodine Deficiency Control Project, Project Appraisal Document, 1996 UNICEF Indonesia. Elimination of Iodine Deficiency Disorders. 2004
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