New Zealand - South Pacific District of Kiwanis International

Iodine Deficiency Disorders in Bhutan UNICEF Logo

First Progress Report to the US National Committee for UNICEF for the Control of Iodine Deficiency Disorders in Bhutan

PBA SC/97/0230-1

Prepared by:
UNICEF Thimphu
June 1998

UNICEF Progress Report No. First
Assisted Country Bhutan
Assisted Project Nutrition (IDD)
Total Funds Pledged US$ 84,372
PBA Numbers SC/97/0230-1
P/L Number 9224
Contribution Number 97023000
Date Prepared June 1998
Period Covered January 1997 to May 1998


Bhutan Basic Data

Executive Summary

Project Background

Project Accomplishments during the Reporting Period
  A. Salt Iodization Plant
  B. Social Mobilization to Promote use of Iodized Salt
  C. Strengthening Regular Monitoring System
  D. Cyclic Monitoring

Future Workplan

Utilization Report

Bhutan Basic Data.

( 1994 data - unless otherwise specified )

Total population (1997) 600,000
Annual population growth rate 3.1%
Estimated urban population 10%
Total fertility rate 6.2
Crude birth rate 4.0%
Crude death rate 0.9%
Life expectancy at birth 66 years
Age structure (estimated % of population) 0-4 years 17%
  0- 14 years 45%
Infant Mortality Rate 70 per 1,000 births
Under Five Mortality Rate 96 per 1,000 births
Maternal Mortality Rate 380 per 100,000 births
Estimated adult literacy rate 54 %
Estimated primary school gross enrolment rate (1995) 70%
Proportion of girls among primary students (1997) 45 %
Completion rate for primary education (1997) total/boys/girls 61%/60%/64%
Per capita GDP (1995) US$420

Key Events in Development

Colombo Plan 1962
Joining of United Nations 1971
Joining of South Asia Association for Regional Cooperation 1985
Signing of Convention of the Rights of the Child 1991
Achievement Universal Coverage of Immunization 1991
Preparation of National Plan of Action for Children 1992

Executive Summary.

1. UNICEF Thimphu has received total contributions of US$ 84.372.00 from the Kiwanis Club through the US National Committee. The funds are being used to support the Royal Government of Bhutan's efforts to achieve universal salt iodization (USI) and eliminate iodine deficiency diseases (IDD) in Bhutan.

2. From the total contribution, a sum of US$ 69,090.95, or 82%, has been utilized.

3. The Kiwanis contribution has been used to support all IDD related activities. Key activities that have taken place during the reporting period include the signing of the IDD Statement by the Je Khenpo (Chief Abbot), procurement of a salt iodization plant, implementation of enhanced monitoring system as per the 1996 study recommendations and the first cyclic monitoring in five districts.

Project Background.

4. Iodine deficiency disorders (IDD) have long been a major public health problem in Bhutan. Over the past three decades several studies have been conducted on the prevalence of IDD in Bhutan. The first published report was by two English doctors who spent five weeks in Bhutan in 1964. While these doctors did not conduct an entirely empirical study to specifically investigate goitre, they reported that goitre among the population was "so prevalent as to be taken for granted".

5. A nationwide study in 1983 reported a mean goitre prevalence of 64.5 per cent; a high prevalence of cretinism and low urinary iodine concentration in the majority of the population.

6. Based upon the findings of the 1983 study, the Royal Government of Bhutan, formulated and introduced a coordinated multi-sectoral Iodine Deficiency Disorders Control Program (IDDCP) in 1984. The main components of IDDCP were salt iodization and distribution (introduced in April, 1985); iodized oil injections in high risk areas; monitoring iodine content of salt; evaluation of the program and community level education. UNICEF supported the program with the establishment of a salt iodization plant in Phuentsholing, and the supply of potassium iodate, packaging materials and social mobilization inputs.

7. A nationwide internal program evaluation of IDDCP was carried out in 1991-92. The results showed that as compared to 1983, there was a considerable reduction in the prevalence of goitre and cretinism and improvement in the urinary iodine status of the population. This was attributed to the successful salt iodization program as reflected in over 95 per cent salt samples at household level having adequate amount of iodine.

8. In mid-1996, a national assessment was undertaken to track progress towards the sustainable elimination of iodine deficiency disorders in Bhutan. The assessment was conducted jointly by Nutrition Section, Division of Health, Royal Government of Bhutan, International Council for Control of Iodine Deficiency Disorders (ICCIDD), New Delhi (India), UNICEF, WHO, and The Micronutrient Initiative, Ottawa (Canada). The report of this study was reviewed by the Royal Government of Bhutan in September 1996. The recommendations emerging out of the findings of the assessment provide a framework for future action to maintain progress towards the sustainable elimination of IDD in Bhutan by the year 2000.

9. The study found that 82 per cent of salt samples at household level had adequate iodine as compared to 95 per cent to 96.5 per cent of salt samples in the 1991-92 study. The low levels of iodine in salt at household level in the study could also explain the observation that 24 per cent of school children had urinary iodine excretion less than 100g/l as compared to only 13 per cent to 16 per cent in 1991-92 study.

10. The 1996 study results indicated that total goitre rate (TGR) was on the decline in Bhutan, however the expected 50 per cent reduction was not observed. The expected reduction may have been achieved if the population had continued to receive adequate amounts of iodine during the period 1991-92 to 1996.

11. The report indicated that since 1994, there was a breakdown in monitoring of iodine content of salt at the production level at the Salt iodization Plant (SIP), Phuentsholing. In addition, the salt crusher was also not properly functioning many times . Moreover, since 1994, there had also been consistent problems in the regular procurement of common salt by BSE, Phuentsholing. These resulted in retailers buying salt from across the Indo-Bhutan border directly, thereby having no control over iodine content of salt. These factors together probably resulted in salt having an inadequate and non-uniform iodine content as observed in the community.

12. There was also a breakdown in the monitoring of iodized salt at the community level. The total number of salt samples analyzed per district were less than the recommended targets. The quarterly salt monitoring reports sent from the district to PHL, Thimphu were incomplete and irregular. There was no system of providing feedback on salt monitoring to the District Administration, Health Department, Bhutan Salt Enterprise (BSE), Phuentsholing and other stakeholders for any corrective action.

13. Based on these findings and the recommendations, the Bhutanese government reviewed their plan of action to reach the year 2000 goal of elimination of iodine deficiency disorders. The monitoring system has been strengthened. The district hospitals are being provided with laboratory equipment in order to do the salt analysis for iodine content by titration method at the district level. The school children have been included in the regular monitoring, to ensure a multi-sectoral approach. A revised strategy for training health staff was done. Furthermore since April 1998, cyclic monitoring for IDDCP has also been put in place and Bhutan may be one of the first countries in the region to have done so. With all these efforts and with the financial support from Kiwanis, Bhutan is well placed to reach the year 2000 goal.

Project Accomplishments during the Reporting Period.

The following key activities were conducted during the reporting period:

A. Salt Iodization Plant.

14. With the Kiwanis contribution, UNICEF procured on behalf of the Ministry of Trade and Industry a salt iodization plant. The new salt iodization plant will replace the old plant that was supplied by UNICEF 12 years ago. One of the contributing factors for shortage of adequately iodized salt at the household level was the constant breakdown of old iodization plant.

15. The salt iodization plant has arrived and is awaiting the official handover from the Ministry of Trade and Industry to the proprietor of the salt plant. As the salt plant has been privatized since 1994, it was agreed that UNICEF will hand over the new salt iodization machine to the Ministry of Trade and Industry who is in charge of private sector business. There have been several rounds of discussion between UNICEF, Ministry of Trade and Industries, Bhutan Salt Enterprise and the Health Division to discuss the establishment of a revolving fund. This fund is aimed at sustaining the achievement made to date in salt iodization in Bhutan by using the cost recovered from the new iodization plant.

16. Although initially the proposal was to procure two salt iodization plants, it was decided to procure only one for the time being. This was decided after UNICEF consultation with the salt plant managers, as well as with Health Division and Ministry of Trade and Industry officials and was unable to determine, beyond reasonable doubt, whether a second salt plant would in fact increase access to iodized salt at affordable prices.

B. Social Mobilization to Promote Use of Iodized Salt

17. Based on the fact that religion plays a very important role in the every day life of the general population and religious practitioners are deeply revered, the Je Khenpo (chief abbot or supreme religious head) was requested to issue a statement on the importance of consuming iodized salt to eliminate IDD. On 30 August 1997, the statement was signed by His Holiness the Je Khenpo at a ceremony attended by most of the senior officials of Ministerial rank and by heads of UN agencies. The statement signing was followed by a function at one of the larger High Schools in the capital where school children and teacher from many schools gathered to receive blessings from His Holiness the Je Khenpo and to get information on IDD.

18. On the same day a women's exhibition football match was organized at the national sports stadium to promote iodized salt. Messages on the importance of iodized salt was given over the public address system during the football match. Health workers and UNICEF staff distributed information leaflets and demonstrated salt testing for iodine content by rapid test kit as well as by titration method. The proprietor of the salt iodization plant distributed small packets of iodized salt.

19. Coinciding with the National Day on 17 December, 1997, an information leaflet on IDD together with the signed statement was distributed to all the schools throughout the country. School children were provided with short information sessions on the importance of consuming iodized salt and given the leaflet to share the information with their families. As support for the leaflet distribution, a supplement on IDD was published in the weekly national newspaper, "Kuensel".

20. During the Winter Scout camp where 275 school children from all parts of the country gathered to be trained as scouts and peer leaders, information on IDD was shared with them for further dissemination to family, friends and relatives.

C. Strengthening Regular Monitoring System

21. In a society which is geographically dispersed, where communications are difficult and literacy rate is still low, efforts are necessary to ensure that salt consumed at the household is monitored well for adequacy of iodine content. Some of the reasons cited for breakdown in the collection of monitoring data was insufficiency of reporting forms at the field level, as well as bulky/unnecessary information required by the reporting format. External experts were consulted and major modifications were made on the reporting formats. The modified formats have become more user friendly, and now requires only essential information. One single book of report formats contains enough forms for at least three years.

22. To strengthen the district hospital capacity for cross checking (by titration method) salt samples from retail shops and households that are tested by rapid test kits by field based health workers and school teachers, UNICEF provided laboratory equipment using the Kiwanis funds. Equipment provided to the 20 district hospitals and the central level Public Health Laboratory, were digital weighing scales for preparing reagents, water distillation units, glass pipettes and tubes and rapid test kits for distribution to field level staff.

23. As part of strengthening the monitoring system, 90 health workers from seven districts were provided refresher training on IDD monitoring. At the same time 20 laboratory technicians were also given refresher training on salt analysis by the titration method.

24. Monitoring of iodine content in salt involves many partners. Monitoring of salt at household level involves school children and teachers. At the retail, and sometimes also household, level the health workers are responsible. Ministry of Trade and Industries officials are responsible for taking action against retailers/wholesalers who import uniodized salt in to the country. Since monitoring involved cross sectoral people it was decided to develop a booklet that spelt out the roles and responsibilities of all partners. The first of the booklet "The Path to Eliminate IDD", gives basic information on IDD and the second part spells out the roles and responsibilities. The book is under print and it is hoped that it will be distributed to the members of the National Assembly in July 1998.

D. Cyclic Monitoring

25. Bhutan may be one of the first countries in the region to have begun cyclic monitoring in addition to the regular monitoring system. Recommendation of 1996 study, was to divide the country into five zones of four districts each and one zone per year to be covered. In each zone 30 clusters or Community/Primary schools will be randomly selected and 40 school children between 6-1 1 years of age will be examined for goitre grading. Urine and salt samples will be randomly collected from 25 per cent of the examined children. Per zone per year 1200 children will be examined for goitre grading and laboratory analysis of 300 urine and salt samples respectively for iodine content. The whole country would thus be covered in a phased manner in five years. The cycle can be repeated after five years so that each zone is surveyed once in five years. At the end of the current plan period (2001) a national evaluation will be conducted by an external team using the same 30 cluster sampling method. The 30 cluster sampling method was also used for the 1996 study.

26. In late April 1998, the first cyclic monitoring exercise was conducted. Five districts were selected instead of four to compensate for the time lost in 1997, As mentioned in the methodology mentioned above, a total of 1200 school children in the age range of 6-11 years were examined for goitre grading and 300 urine and salt samples were collected. The study team was composed of local health workers, staff of the central Nutrition Section and one UNICEF staff. The samples of urine and salt are being analyzed at the Public Health Laboratory in Thimphu and the data collected is under analysis. Cyclic monitoring result is expected to be ready in August 1998. Kiwanis funds were used for providing a two day training for the surveyors, printing of data collection forms, and transport for field staff.

Future Workplan.

27. The National Commission for the Control of Iodine Deficiency Disorders (NCCIDD) is expected to meet shortly to discuss the terms and conditions of the lease agreement between BSE and the government. Other issues such as revised ToR for NCCIDD, and establishment of a revolving fund for salt iodization plant maintenance and to cover the increased cost of potassium iodate.

28. The stock of potassium iodate purchased by UNICEF in the early 1990s is nearly depleted. The salt plant owner is expected to purchase potassium iodate which is expensive. Although exact figures are not available at this stage, the cost of iodized salt is expected to increase if Bhutan Salt Enterprise is expected to bear the cost of potassium iodate.

29. To maintain the momentum created by the Statement of the Je Khenpo in 1996, the official statement will be reproduced in poster form and distributed to all health centers and schools in two languages.

30. Radio messages on IDD will also be developed to further promote proper use of iodized salt and correct storage of iodized salt. Messages on correct storage will target the remote nomadic communities like the yak herders who are known for having large reserve stocks of salt. Radio messages will also target shopkeepers to encourage them to use rapid test kits while buying salt from wholesalers.

31. The IDD booklet, once approved by the Health Conference, will be distributed widely to all partners as well as National assembly members who play an active role in disseminating information to the communities. The role of the Ministry of Trade, shopkeepers, etc. will also be defined and elaborated on. Any issues and problems will be addressed in consultation with the stakeholders more clearly.



Utilization of Donor Funds.

(all amounts in US$)
Assisted Country BHUTAN
Donor B641 USA National Committee
PBA No. SC 97/0230-1
Program No. YH/311
Description Health and Nutrition
Period Covered by Report: 02/09/97 - 15/06/98
Total available for program implementation: $84,372.00

Call Forward Number Description CF Value
Subtotal for Supplies $40,673.00
Subtotal for Cash $28,414.00

Grand total of funds committed $69,090.95
Total funds still available $15,281.05

Period Covered by Report:   01/01/97 - 15/06/98

Date Prepared   15/06/1998

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