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Population 1
Population: 79,999 millions
Population annual growth rate: 2.1%
Population < 18 years: 34,124 thousands; <5 yrs: 9,758 thousands
Crude birth rate: 25 per 1000
Life expectancy at birth: 70 years
Iodine Nutrition Situation
Median urinary iodine concentration was 201 µg/L (National survey, 2003) which was a significant increased from 71 µg/L in 1978. The results indicate that the proportion of moderately to severely iodine deficient children decreased from 35.8% to 11.4% and children with an urinary iodine concentration below the WHO cut off 100 µg/L was 23.8%. 3
Iodized salt Coverage
Household consumed iodized salt 1 : 24 %.
However a more recent National Nutrition Survey (2003) showed that household utilisation of iodized salt increased to 56.4%.
Salt Situation Analysis
Production
Based on a survey conducted by the Department of Health (DOH) in January 2000, there are 32 large and 60 medium salt producers/importers in the country and of these, 7 of the largest producers control an estimated 80% of the salt supply. In the 1999 Philippine Foreign Trade Statistics, the country imported nearly 400,000 MT of salt of which 385,000 MT was classified as industrial salt (non-iodized). Importation is mainly from India , Australia and Jordan . Local salt production is estimated at between 160,000 to 220,000 MT per year, although records are poorly kept. It is not accurately known how much of the local or imported salt is edible, although much of the imported salt classified as industrial can actually pass as food grade salt and is being sold in markets. Local production is centered in Pangasinan, Bulacan and Mindoro Occidental. The project is now in the process of updating the Salt Industry situation analysis to further clarify the flow of salt from importation/production to the retail markets. 4
The increased availability of iodised salt in the market is due to two reasons. Firstly, large importers have increased the importation of iodized salt due because of increased market demand. This requires minimum investment and iodisation is at lower cost (due to efficiency and economies of scale). It is important to note that imported iodised salt is applied with the 10% Value Added Tax (VAT) while non-iodized salt is VAT-free. The Department of Science and Technology (DOST) has prepared a technical justification for the removal of VAT on iodized salt but this has not been granted so far as the country reels in the wake of a possible fiscal crisis. The second reason is that the large players have already made large investments in salt iodisation machines. Many of the medium and small scale producers still need support to acquire iodisation technology. 4
The small-scale salt producers are the most affected by the "Patil sa Asin" (USI) law as they have limited financial resources with which to build capacity to iodise salt. To address this, the Cooperative Development Authority is trying to organise the small scale producers into cooperatives which will make them better able to acquire the necessary business and technological capacity to produce iodised salt. The Bureau of Food and Drugs
(BFAD) and its regional offices are tasked to provide the technical support to this initiative. 3
Consumption
• The Food and Nutrition Research Institute estimates per capita salt consumption at 1.875 kg per year. 4
• In the 2003 National Nutrition Survey (NNS) preliminary results, national household utilization was estimated at 56.4%. Awareness of iodised salt was recorded at 79.5%. A total of 38% of the respondents claimed to utilize iodised salt and this was validated through salt testing. Other users were actually not aware that they were using iodised salt.
Universal Salt Iodization Program
Information, Education, Communication (IEC ) Activities 3
An IEC campaign has been developed to focus on the consumers through both the health and education systems in order to improve the level of knowledge about the benefits of iodised salt. The association of iodised salt with goitre prevention is being better understood in most areas as shown in recent surveys and the campaign now includes the importance of iodised salt inn brain development and associated intelligence.
The IEC materials consist of posters, leaflets, and market signage and have been distributed nationwide over the past 2 years. A major element of this campaign is the finalisation of a module and teacher's guide, through the Department of Education, for the integration of basic messages of iodised salt into the elementary school curriculum.
Legislation
To strengthen the National Salt Iodization Program (NSIP) of the GOP, the Philippine Congress enacted Republic Act (R.A.) No. 8172, "An Act of promoting Salt Iodisation Nationwide and Other Purposes", otherwise known as the ASIN Law in December 1995. It requires that all food-grade salt for human or animal consumption must be iodised. It also mandates all salt producers, importers and traders to iodise salt and make it available to all Filipinos.
The ASIN Law is supported by the Food Fortification Law (RA 8976) and the Food, Drugs and Cosmetics Act (RA 3720). At the local level many provinces, cities and municipalities have passed resolutions and/or local ordinances which support the implementation of the ASIN Law, although the level of implementation does vary across the country, with some LGUs (Local Government Units) strictly enforcing the law and others more lax. 3
Programme Monitoring and Evaluation
Programme monitoring is conducted through the government Sub Committee on Salt. It is also taken up during regular DOH national staff meetings, and during interzonal health meetings, regional and local level meetings. This process has essentially worked well and progress indicators have been established using available routine data and information. 3
In 2003, new initiatives were developed and instituted to accelerate progress to achieve the goal of USI. These efforts have been spearheaded by the Department of Health and supported by UNICEF, Kiwanis and ICCIDD. 2
- Salt Producers and Importers. Both producers and Importers of iodised salt are required to register and acquire a License to Operate (LTO) from the BFAD.
- Market Monitoring. This is widely conducted through the Patak sa Asin campaign.
- Household Utilization Monitoring. The FNRI conducts the National Nutrition Survey (NNS) every 5 years, the latest of which is in 2003.
National Coordination and Leadership
As mandated by the ASIN Law, the over-all management of the National Salt Iodisation Program
(NSIP) is the responsibility of the Department of Health (DOH). Since 2001, the Bureau of Food and Drugs (BFAD) of the DOH was assigned as the implementing agency for the National Salt Iodisation Program (NSIP). BFAD is supported by Salt Iodisation Advisory Board (SIAB) which functions as a policy and coordinating body. It is composed of the members of National Nutrition Council (NNC) Governing Board: the Secretaries of Health, Agriculture, Social Welfare and Development, Education, Science and Technology, Interior and Local Government, Labor and Employment, Trade and Industry, Budget and Management and National Economic and Development Authority, three private sector representatives, representatives from the
Department of Environment and Natural Resources, medical profession and salt manufacturers.
NCDPC chairs an inter-agency Subcommittee on Salt which manages the NSIP implementation. Members of the subcommittee include DOH-BFAD, other government agencies, UNICEF, Salt Producers, Consumer groups and other stakeholders. With the enactment of the Food Fortification Law in 2000, the Subcommittee on Salt reports to the National Food Fortification Program (NFFP) Steering Committee is composed of the same agencies as SIAB but with lower-level representation. This is currently being chaired by the NCDPC Director.
Other Interventions 4
The DOH has stopped Iodine Oil Supplementation since the enactment of the ASIN Law although some LGUs, continue to purchase iodised oil capsules for their own use. The DOH is in the process of releasing updated guidelines on iodised oil supplementation. Iodised oil supplementation as a solution may be considered on a case to case basis and would be coordinated with DOH, which will be releasing new guidelines on supplementation. This was expected to be discussed with the release by FNRI of the UIE findings of the 2003 NNS towards the end of 2004.
Key Lessons Learned 4
• A common vision together with integrated program planning from the national to the local level helped to improve commitment, momentum and impact. SIP became a priority action and everyone understood program direction.
• Partnership building helped reinforce effectiveness and the achievement of success especially at the local government level. Enforcement of the ASIN Law required partnerships at different levels.
• Showing firmness and consistency in monitoring leveled the playing field and enhanced compliance to the law especially by the local traders and retailers.
• The support of Local Government Units is necessary for the long term success of the program. A sense of ownership strengthened the resolve of local executives to support salt iodisation. The leagues facilitated coordination.
• Salt industry collaboration and coordination is critical. They are willing to support if they are involved and if they sense a strong government commitment.
Challenges and Constraints
Monitoring and Quality Control. There are a number of factors which are affecting the capacity of the DOH programme managers to improve their performance in monitoring and quality controls, which includes: a) already excessive workload b) an inability to properly analyse and manage the situation at field level and c) inadequate leadership for programme planning and management, including coordination with other agencies. 3
Law Enforcement . Salt industry, except for producers of branded pre-packed iodised salt compliance to the iodization standards set by ASIN Law is difficult to gauge (especially for producers who supply takal iodised salt). Few of these salt producers/importers keep consistent records of quality assurance. In worst cases, records are not being kept at all. The biggest issue in the compliance of the salt industry is the capacity of BFAD to monitor and enforce the law. However, inspection of warehouses is generally not regular. The dissemination and consolidation of inspection reports is not systematic and is seldom done by the BFAD national office. 4
Salt Industry . In general, the salt industry does not promote their products to emphasize the health benefits to the consumers. This is because salt is still considered a common product where the effect of branding is not substantial; the industry feels that investing in promotions should promote iodised salt in general and not the particular brand. Two of the largest producers/importers ( Salinas and Salt Asia), however do conduct consistent promotion on the problem of IDD, the use of iodized salt and their respective brands. 4
Future Plans for Sustained IDD Elimination 3
DOH and UNICEF prepared a Work Plan for 2005-06 as follows:
The DOH will:
• Sustain and re-affirm a continued commitment of government at the highest levels to USI and include a willingness to address the issues and a commitment to accelerate the pace of progress.
• Assign an Under-Secretary or Director to lead the Subcommittee on Salt in order to ensure better coordination.
• Confirm the Bureau of Food and Drugs (BFAD) commitment to the programme through the implementation of initiatives to build capacity, monitor and regulate salt iodisation based on approved standards.
• Strengthen the monitoring processes for imported and local salt, by, for example, expanded and improved coordination among government agencies.
• Build capacity of the salt producers towards gaining an improved compliance to licensing standards and quality assurance and controls.
• Encourage and facilitate co-operatives amongst the small scale salt producers for commercial adoption of salt iodisation from this group.
• Include titration in the 2005 survey on household utilization of iodised salt.
UNICEF will:
• Continually highlight the issues and concerns to the Department of Health and all stakeholders in order to insure a full commitment to USI and proposed actions, including periodic reviews.
• Develop and present detailed needs and ideas to the DOH to promote acceleration for the programme.
• Advocate that efforts need to be sustained to keep the programme moving through supportive systems, advocacy at different levels, reducing bureaucracy and establishing an improved information flow.
• Focus on providing assistance to the DOH in strengthening programming and networking amongst all involved agencies, whilst promoting Government as the lead agency responsible.
• Facilitate the coordination and communication between the industry and others stakeholders.
References
1) UNICEF. The State of the World's Children. 2005
2) Eastman, CJ. Reports from the Regions and the Countries by ICCIDD Regional Coordinators in Towards the Global Elimination of Brain Damage Due to Iodine Deficiency. Oxford University Press, 2004.
3) UNICEF. Achieving and Sustaining Universal Salt Iodization in the Philippines . Action Plan for 2005. UNICEF Philippines , 2005.
4) UNICEF. Salt iodisation for iodine deficiency disorder elimination in the Philippines . Progress Report. UNICEF Philippines, 01 February 2004 - 30 September 2004 .
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