# Global Alliance for Improved Nutrition (GAIN) – Universal Salt Iodization (USI) – December 2014 version

We have published a more recent review of this organization. See our most recent report on GAIN.

The Global Alliance for Improved Nutrition (GAIN) is a standout organization, and an organization that we feel offers donors an outstanding opportunity to accomplish good with their donations.

Published: December 2014

## Summary

What do they do? The Global Alliance for Improved Nutrition (GAIN: http://www.gainhealth.org) works to improve health through staple foods that are fortified with essential nutrients. This page focuses exclusively on its work assisting universal salt iodization (USI) programs. GAIN’s USI activities vary considerably across countries and include advocacy, technical assistance, supplying equipment, training government officials and salt producers, and monitoring, among others. (More)

Does it work? There is strong evidence that salt iodization programs have a significant, positive effect on children’s cognitive development and do so cost-effectively. We have not seen compelling evidence that rates of salt iodization have increased in the countries GAIN has worked in nor that observed changes should be attributed to GAIN's work. We have looked more closely at four case studies, but the information we have is not fully compelling, in part because GAIN's work is often a few steps removed from the iodization process and because we have only a limited understanding of GAIN's role in each country. (More)

What do you get for your dollar? Our work on the cost-effectiveness of salt iodization is ongoing, but we believe it may be highly cost-effective. GAIN states that it has expanded iodization coverage for $0.05-$0.20 per person in three example countries, though this work involved other partners and the cost is only GAIN’s share. We have not vetted these estimates. (More)

Is there room for more funding? GAIN’s main funding source for its USI work is scheduled to end in 2015 (though there is a chance it will be renewed). GAIN is seeking funding to continue this work. We have not yet seen details of how GAIN would use additional funding. (More)

GAIN-USI is a standout because:

• It supports salt iodization programs. There is strong evidence that salt iodization programs have a significant, positive effect on children’s cognitive development and do so cost-effectively. (More in our full report on salt iodization.)

Major unresolved issues include:

• We have thus far been unable to document a demonstrable track record of impact; we believe it may have had significant impacts but we are unable to be confident in this with what we know now.

## Our review process

We contacted GAIN in 2014 as part of our review of ICCIDD (more). Greg Garrett, GAIN Director of Large-Scale Food Fortification, sits on ICCIDD’s board. As we learned more about GAIN’s work on USI from these conversations, we decided to invite GAIN to apply for a recommendation for this work. We have published notes from four conversations with GAIN in 2014: March 11, April 30, May 19, and June 19. We also asked GAIN to submit documents to help us understand what activities the Partnership Project carried out, which actors were responsible for which activities, how much the work cost, what changes have resulted from the work, and the evidence for any changes. After reviewing the documents GAIN submitted, we drafted an earlier version of this report and asked GAIN to review it prior to publication.

We also spoke with GAIN in 2012, primarily about an opportunity to fund the purchase of potassium iodate in Ethiopia. We published notes from two conversations in 2012, on June 5 and July 18. We did not ultimately recommend funding for the opportunity at that time.

Our 2012 review of GAIN is available here.

## What do they do?

The Global Alliance for Improved Nutrition (GAIN) works to improve health through staple foods that are fortified with essential nutrients.1 This page focuses exclusively on its work assisting universal salt iodization (USI) programs. GAIN’s USI activities vary considerably across countries and include advocacy, technical assistance, supplying equipment, training government officials and salt producers, and monitoring, among others.

GAIN’s USI program was established in 2008 with a grant from the Bill and Melinda Gates Foundation for the GAIN-UNICEF USI Partnership Project (hereafter, “Partnership Project”).2

GAIN told us that it chose its target countries based primarily on the burden of iodine deficiency3 and the anticipated difficulty of increasing the amount and quality of salt iodization. Generally the largest salt producers have already started iodizing their salt, and the smallest producers are more difficult to reach and are most affected by the additional cost of iodine in their salt production. Thus GAIN has targeted iodine-deficient countries with medium-sized salt producers that are not yet iodizing adequately.4 GAIN told us that it focuses on increasing the iodization content of salt that is inadequately iodized, rather than on getting additional salt producers to start iodizing.5

### Four case studies of GAIN’s USI work

GAIN has recently worked on salt iodization in 16 countries, 14 of which have been funded by the Partnership Project.6 GAIN has shared some information about its activities and goals in these countries, particularly the 11 countries that were both part of the original set of Partnership Project countries and in which GAIN works currently.7 It provided further information on four countries, which account for 50% of GAIN’s portion of the Partnership’s budget.8

Country GAIN country budget % of GAIN's Partnership budget Claimed additional reach Claimed cost per additional person reached
India $3,869,069 19% 76,133,000$0.05
Ethiopia $2,686,229 13% 17,654,000$0.15
Philippines $1,840,238 9% No survey data N/A Bangladesh$1,680,838 8% 9,077,000 $0.19 Total$10,076,374 50% N/A N/A

We have not seen any additional information on how GAIN calculated the “additional reach” figures in the above table.

We describe what we’ve learned about these four case studies below, including both what we know about GAIN’s activities and about the impact of these activities. We have varying levels of detail on the activities described below. Detail on activities varies from concrete to vague and in many cases it was not clear to us whether the work was carried out by GAIN or by one of its partners.

GAIN provided some details on the Partnership Project’s work in Bangladesh in 2012 and 2013. The reports often do not distinguish between work carried out by GAIN and by other partners. This work includes:

1. Procuring potassium iodate to serve as the initial stock for a revolving fund. The fund is intended to provide a sustainable supply of potassium iodate for the country.9
2. Providing technical and financial support for the National Micronutrient Survey. Both GAIN and UNICEF worked on this. The report was published in early 2013 and included information about household salt coverage rates and iodine status of at-risk population groups.10
3. Advocating to the government for a revised salt law and stricter enforcement of existing legislation.11 As of mid-2014, the revised law had been drafted and was open for comments.12
4. Working with a selected group of small and medium-sized mills to improve iodization quality. This work included engaging a quality control expert to work with the mills and collecting salts samples from the mills for lab testing.13
5. Promoting the use of Rapid Test Kits (RTK) at a local level to determine whether salt is iodized. Targets of the communication campaign include local government monitors, retailers, and households.14
6. Creating and airing TV programs to educate households on the importance of using iodized salt.15

Have salt iodization rates improved in Bangladesh during the Partnership Project?

Median urinary iodine content for women of reproductive age and for school-aged children decreased between 2004-2005 and 2011-2012 in Bangladesh (140 to 123 µg/l for women, 163 to 146 µg/l for children), though in both years it was in a range that is considered normal.16 The studies also reported the prevalence of iodine deficiency in school-aged children and women (the study found small increases in both groups),17 however it is our understanding that iodine deficiency prevalence figures, as they are generally calculated, are problematic and cannot be taken at face-value.18 The 2005 and 2011-2012 surveys were both high-quality, national surveys, though they used somewhat different sample groups – the 2005 survey included pregnant and lactating women while the 2011-2012 survey did not.19 The same surveys also measured household use of adequately iodized salt (>15 ppm) and found that this rose from 51% in 2004-2005 to 58% in 2011-2012, though the use of salt iodized at all (>5 ppm) did not rise (it was about 80% in both surveys).20 Full methodological details are available for both surveys.

GAIN also shared monitoring data from the Bangladesh Salt Iodine Information System (BSIIS). This data includes the percentage of samples tested that fell within various ranges of iodine content: below 15 ppm, 15-30 ppm, 30-50 ppm, more than 50 ppm, “BSTI” (20-50 ppm), and “Salt Law” (45-50 ppm). Below we present data for the percent of samples each month in the “BSTI” and “Salt Law” ranges, averaged by year.21 We do not know how this data was collected, how samples were selected, or the significance of the ranges. We would guess that falling in the “BSTI” or “Salt Law” range would qualify as a positive test result, with the latter being a stricter standard.

Year Average # of samples per month # of months missing Average % of samples in "BSTI" range Average % of samples in "Salt Law" range
2007 128 4 54% 12%
2008 172 1 57% 12%
2009 252 0 56% 12%
2010 576 0 53% 10%
2011 721 0 65% 11%
2012 553 0 64% 13%
2013 602 3 72% 16%
2014 (first half) 700 2 89% 17%

The percentage of samples in the BSTI range has increased since 2010; the number of samples in the narrower Salt Law range was low throughout the period. The number of samples per month was significantly lower in 2007-2009, but has been fairly steady since 2010.

Are changes due to the GAIN’s work?

It is difficult to assess if the observed changes are a result of GAIN’s work. We have not seen high quality information on this question.

#### Ethiopia

GAIN’s activities in Ethiopia include:

1. Replacing iodine donations with a revolving fund to supply iodine sustainably. Previously, Ethiopia received donations of potassium iodate, the chemical used to iodize salt, from donors such as GAIN, UNICEF, and the Micronutrient Initiative.22 GAIN believed this was an unsustainable system,23 did a feasibility study on the possibility of creating a revolving fund maintained by the government of Ethiopia to supply potassium iodate at market prices,24 and helped to set this up.25
2. Purchasing iodization and testing equipment,26 and training salt producers on its use.27 In one case, GAIN purchased a salt iodization machine and installed it at a salt production site.28
3. Training government staff in use of testing equipment. In May 2012, a consultant trained fourteen government trainers on the use and maintenance of machines to check the iodine content of salt.29 We do not know if GAIN funded other training programs.

GAIN reports that the number of households in Ethiopia using iodized salt increased from about 20% in 2005 to over 40% in 2013-2014.30 The 2013-2014 data is based on incomplete results from an ongoing survey.31 We have not vetted the baseline results. We have not seen further information on whether GAIN’s activities in Ethiopia have resulted in improved functioning of the iodization program.

#### India

GAIN’s activities in India include:

1. Advocating to the government to increase attention on the IDD program. Advocacy was aimed at both national and state governments.32 GAIN notes that this work was conducted by ICCIDD with support from GAIN.33 Specific efforts included supporting the National Coalition for Sustained Iodine Intake,34 holding meetings and workshops on progress and plans,35 helping states to create state-level USI coalitions,36 and conducting research on the feasibility of creating a government program to encourage consolidation in the salt industry.37
2. Developing a computerized monitoring information system. GAIN conducted a study of the old monitoring information system and funded user training for the new program; we do not know what other roles GAIN played in the development of the system.38 GAIN reports that as of 2014, all salt officers were using the system and 100% of factory data was being inputted into the system.39
3. Providing technical assistance to iodine labs. ICCIDD, GAIN, and the government of India organized a workshop in 2009 for government officials responsible for testing and regulating iodine context in salt.40 The workshop was led by a consultant (who seems to have been hired by GAIN41) and included lectures and hands-on training.42 The consultant also developed reporting templates for quality assurance activities,43 supplied laboratory equipment,44 and visited five laboratories to inspect them and provide refresher training.45 GAIN, with ICCIDD, also developed a manual for salt iodization quality assurance.46

Have salt iodization rates improved in India during the Partnership Project?

GAIN reports that “AIS (Adequately Iodized Salt) samples went from 72% to 76%” in India.47 We have not seen the underlying data, details of how it was collected, which factories were included, what the timeframe for the change was, or whether the results were sustained.

A 2007 report states that 51.1% of households in India consumed salt with adequate iodine levels,48 but does not give details on how this data was collected. A national 2009 survey targeted only households with children 12-23 months old or where a woman had given birth in the past 12 months49 – this survey found that 71.1% of households were using adequately iodized salt and another 19.3% were using salt that contained low levels of iodine, and the report provided in-depth information on how the data was collected.50 GAIN reports that the rate of households using adquately iodized salt rose to 81.4% in 2012-2013, though it notes that the representativeness of this data is not known.51

It is not clear to us whether the difference between the 2007, 2009, and 2012-2013 findings is likely due to progress in the coverage of iodized salt or to differences in how the surveys were carried out and what groups were targeted for each survey.

Another study, from 2010, surveyed households in 8 states that had been found in the 2005-2006 National Family Health Survey to have below average rates of use of iodized salt. It targeted rural households.52 In these states, it found that use of iodized salt increased from 27% to 47% between 2005-2006 and 2010.53 The report gave only limited details on how the survey was carried out and we do not know if the comparison to the earlier survey is an appropriate one.

Are changes due to the GAIN’s work?

It is always difficult to be confident that a program led to positive changes in cases where rigorous evaluations do not exist. In the case of GAIN’s work in India, it is particularly hard, because:

• GAIN’s work is largely high-level – targeted at national policies and monitoring systems. It is difficult to connect these activities with factory-level and household-level changes.
• As in the other countries GAIN is working in, it is not entirely clear which activities were carried out by GAIN and which were carried out by other partners, particularly UNICEF.
• There may be unrelated changes occurring simultaneously. In particular, GAIN notes that “the consolidation of the salt industry and use of improve[d] production process[es] by many of the large producers are the most signiﬁcant reasons behind the recent improvement in the household coverage of adequately iodised salt in India.”54 (Though it’s also possible that GAIN played a role in these changes.)

#### Philippines

The Philippines is the case study where we believe we have the most concrete information on GAIN’s activities and the direct results of those activities. GAIN shared a “sample monthly project monitoring report,” which contains detailed information on the activities of an “Associate” over the period December 2013 to July 2014. We do not know if GAIN’s work in the Philippines extends beyond the work of this employee.

Work included in the Associate’s report, includes:

1. Visiting salt producers to provide training on quality assurance software and to monitor their iodization levels and quality reporting.55 Poor performance was reported to the government.56
2. Replacing broken iodization equipment.57
3. Purchasing equipment for testing iodine content of salt. GAIN and UNICEF purchased the equipment and funded training in its use.58
4. Organizing and funding national meetings to discuss technical topics related to salt iodization.59
5. Developing supply systems for testing reagents and iodine dosing pumps.60
6. With UNICEF, creating a government-approved seal for products that contain adequately iodized salt.61
7. Working with the government to monitor iodine content of salt during shipping. Monitoring locations include road checkpoints and ports. GAIN’s role appears to be to monitor that checks are occurring as expected.62

GAIN reports the following results of its work:

Most factories which were assisted had less than 1/3 of the samples tested passing the FDA standard and the average iodization is below the minimum. After completing the training and monitoring visits, the factory collected samples achieved at least 80% passing rate, with many above 90%, and the average iodization rates are within standard.63

We have not seen details of how this data was collected, which factories were included, what the timeframe for the change was, or whether the results were sustained.

## Does it work?

### Is there independent evidence that salt iodization is effective?

There is a strong case that fortifying salt with iodine improves the mental function of iodine deficient children with greater improvements the more severe the deficiency. We discuss the evidence for salt iodization extensively here.

### What has GAIN’s impact been on iodization programs in the countries it has worked?

GAIN has worked on iodization in 16 countries64 and has reported iodization coverage rates for 9 countries, all of which are Partnership Project countries. Iodization coverage is generally measured through:

• Proportion of households who are using iodized or adequately iodized salt
• Median urinary iodine concentration (UIC) of the population, pregnant women, or school-aged children

We plan to discuss the meaning and weaknesses of these measures generally in our report on salt iodization. As we discuss above, it is our understanding that iodine deficiency prevalence figures, as they are generally calculated, are problematic and cannot be taken at face-value.

The chart below shows baseline and follow up data for household use of iodized salt. Notes (a) through (f) are in this footnote.65

GAIN-UNICEF Partnership baseline and follow up survey data for use of iodized salt, with 2015 targets (for the 9 countries where updated household data since baseline is available)66

There does not appear to be a clear trend of increasing household use of iodized salt. In three of the countries, use of adequately iodized salt decreased between the baseline and follow up surveys – though use of salt with any iodine increased in these countries. In another four countries, use of adequately iodized salt increased by a small amount. In two countries (Ethiopia and Pakistan), it appears to have increased substantially, though GAIN notes that the results from Ethiopia are preliminary.67

With the exception of the data from Bangladesh, which we discuss in more detail above, we have not vetted this data and in many cases, we have not seen the data sources cited. The data appears to be from sources that were created for other purposes (i.e. in most cases the data does not seem to have been collected for the purpose of evaluating the Partnership Project)68 and may not be fully comparable between baseline and follow up or across countries.

In addition, we have limited information on the role GAIN played in many of the countries and its likely contribution to the changes over time.

As discussed above, we have also gained some limited understanding of GAIN’s impact from four case studies.

## What do you get for your dollar?

### Cost-effectiveness of salt iodization implementation

The cost-effectiveness of a salt iodization program depends on salt intake, the iodine content in salt once it reaches consumers (poor storage, for instance, can result in iodine loss), and the prevalence of iodine deficiency before implementation of the program. We have limited data on the costs of iodization, but estimates range from $0.05-$0.10 per person per year. Salt iodization appears to be within the range of cost-effectiveness of our priority programs.

For more, see our full report on salt iodization.

We have not closely vetted any data on GAIN’s cost-effectiveness. GAIN estimates that in three of the four case study countries discussed above, it has expanded access to adequately iodized salt for $0.05 (India),$0.15 (Ethiopia), and $0.18 (Bangladesh) per person (an estimate for the Philippines was not available).69 We don’t know how GAIN determined the additional reach over the project period, but it appears that this estimate uses the additional reach in each country over the course of the Partnership Project, which may be due in part to work by UNICEF, ICCIDD, governments, and other actors, while the cost figures include only GAIN's costs. GAIN notes that it expects the cost per beneficiary to go down as the project continues.70 ## Is there room for more funding? GAIN is interested in continuing its work on USI after mid-2015, when the Gates Foundation grant for the Partnership Project is due to end.71 We do not know if the Gates Foundation plans to renew its support. GAIN might receive funding for its work from bilateral aid organizations, such as the European Commission and USAID, but currently expects to have a funding gap in 2015.72 We have not yet seen a budget for GAIN’s USI program, and we are not sure how many countries or what activities would be funded in the absence of significant new funding. If funding from the Gates Foundation does in fact end in 2015, it is easy to imagine that GAIN would need to significantly scale down its USI work due to lack of funding. GAIN told us that it has very little unrestricted funding, so it’s unlikely to be able to reallocate funds from other programs to continue to support USI work.73 It is possible that resources that are shared across programs (such as some staff), could be shifted toward other programs if resources for USI increased, but we would guess that this effect would be small. In one case, GAIN used a small amount of funding designated for large scale fortification to support work on USI.74 ## Major questions for further investigation • What has GAIN’s role been in each of the countries (or a significant portion of the countries) it has worked in? GAIN provided some details from four countries, but we would like to know whether our understanding is reasonably complete, what activities were carried out by GAIN versus its partners, and, in some cases, to understand these activities at a higher level of detail. We would also be interested in learning more about GAIN’s work in other countries. • What changes have resulted from GAIN’s work in each country? Ultimately we would like to understand whether and to what degree iodine deficiency disorders have been reduced in the countries GAIN has worked in and how big of a part GAIN’s work played in these changes. Working toward that understanding may include answering question such as: What policy changes has GAIN affected and how would reallocated resources have been used otherwise? How does the quality of iodization change at factories that GAIN works with? Has the supply of potassium iodate increased and/or become more stable in countries where GAIN has created revolving funds? Is testing equipment used and maintained? Have policymakers’ and households’ beliefs about the importance of iodization changed? • How are estimates of increased reach calculated and are these estimates reasonable? In order to estimate GAIN’s cost-effectiveness, we would need additional information to allow us to vet estimates of how many additional people have been reached with iodized salt as a result of the Partnership Program. If possible, we would like to estimate what portion of the costs and additional reach are due to GAIN’s program, to get a GAIN-specific estimate. • How would GAIN use additional funding? How likely is it to receive funding from other sources? The grant that established the Partnership Project ends in 2015, and there is uncertainty about what funding will be available after that time. We have not yet discussed with GAIN how it would prioritize USI work at different levels of funding. ## Sources Document Source Bangladesh National Micronutrient Survey (2011-2012) Source (archive) Bangladesh Salt Iodization Information System Source (archive) Consultant work status report - India (October 2010) Source Data from Bangladesh Salt Iodization Info System Source Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia Source Ethiopia Indicator Matrix Source GAIN Email from Greg S. Garrett, October 8th, 2014 Unpublished GAIN presentation for GiveWell Source GAIN-UNICEF Universal Salt Iodization Partnership Project Source GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 5) Unpublished* GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6) Unpublished* GAIN-UNICEF USI Partnership Project Annual Report - without financials (Year 6) Unpublished* GiveWell's non-verbatim summary of a conversation with Greg Garrett and Jonathan Gorstein, April 30, 2014 Source GiveWell's non-verbatim summary of a conversation with Greg Garrett and Rizwan Yusufali, May 19, 2014 Source GiveWell's non-verbatim summary of a conversation with Rizwan Yusufali, June 19, 2014 Source India Indicator Matrix Source Iodized Salt Coverage Study Conducted Across Eight States in India (2010) Source KIO3 supply center brief Source Philippines activities (December 2013 to July 2014) Source Philippines case study Source Rah et al 2013 Source (archive) Rizwan Yusufali, email to GiveWell, July 16, 2014 Unpublished Salt Management Information System - India Source Strengthening the supply chain of iodized salt through national and state level activities - India Source Training of Trainers in Use and Maintenance of WYD Iodine Checkers - Ethiopia Unpublished UNICEF India Coverage Evaluation Survey (2009) Source (archive) Universal Salt Iodisation (USI) in India – Current Situation and Proposed Actions Source Yusuf et al 2008 Source (archive) Zimmerman and Andersson 2012 Source (archive) * GAIN has said these annual reports may be available upon request. Email info@givewell.org if you are interested in viewing a copy. • 1. “The Global Alliance for Improved Nutrition (GAIN) was established in 2002. It initially focused on scaling up nutritional interventions such as staple food fortification.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Rizwan Yusufali, May 19, 2014. • 2. “Work in 14 countries is funded through the GAIN-UNICEF USI Partnership Project, which was GAIN’s first foray into salt iodization. GAIN was the initiator of the USI Partnership Project, and the Bill and Melinda Gates Foundation ultimately funded UNICEF to work alongside GAIN, bringing with it its USI experience, particularly in policy and advocacy in salt iodization.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Rizwan Yusufali, May 19, 2014. "The GAIN-UNICEF Universal Salt Iodization Partnership Project responds to this requirement for new models of salt iodization. GAIN and UNICEF received funding from the Bill and Melinda Gates Foundation in 2008 to contribute to global efforts to eliminate iodine deficiency through salt iodization in 13 countries with the lowest coverage of iodized salt and the greatest burden of iodine deficiency." GAIN-UNICEF Universal Salt Iodization Partnership Project. • 3. “While there are more than 30 countries that are still classified as iodine deficient, the Partnership Project focuses on just 14-15 most of which represent the highest burden countries (e.g. India, Ethiopia, Bangladesh). Among these Partnership countries, an average of about ~60% of household salt being consumed is adequately iodized (which needs to be “sustained”), about 25% of household salt is iodized but not sufficiently (in which iodization levels need to be “improved”), and about 10-15% of household salt is not iodized at all (to which iodization needs to be “expanded”). (All data are approximations.)... The Partnership Project selected countries in which to improve iodization programs based on household surveys and salt industry assessments. Currently GAIN uses data from surveys administered by other organizations, including the Demographic and Health Surveys (DHS), the UNICEF Multiple Indicator Cluster Survey (MICS), and government surveys. The USI Partnership Project is also developing its own data-collection capacity. It is rolling out five national surveys on household iodine coverage and is adding questions related to iodine to governmental or existing surveys in six additional countries.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Jonathan Gorstein, April 30, 2014. • 4. “In some countries, such as Ghana and Senegal, there are thousands of small salt producers. It is costlier to run iodization program in these countries, because GAIN must apply significant resources to work with these thousands of salt producers or use salt extenders. In some of these countries, GAIN lacks the resources to address iodization adequately, though GAIN would work in these countries if a donor provided funds for that purpose. This work to expand iodization among small-scale salt producers is easier in countries where salt production is being consolidated, such as in Bangladesh. In these countries, GAIN incentivizes producers to iodize salt and monitors their progress.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Jonathan Gorstein, April 30, 2014. • 5. “GAIN’s primary focus is on improving the levels of salt iodization in regions that have insufficient iodized salt although it also works to sustain iodization levels in its core countries as well as expanding iodization. GAIN believes that a focus on improving levels of iodization provides the most promising opportunities to improve iodine health at low cost and among large parts of populations. It appears to be more cost-effective than expanding iodization programs into areas that are not currently iodizing their salt at all, primarily because those regions typically have a highly fragmented salt industry and therefore require different models to expand iodization.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Jonathan Gorstein, April 30, 2014. • 6. “GAIN’s current program portfolio promotes USI in 16 countries with high rates of iodine deficiency and low household coverage of iodized salt: Bangladesh, China, India, Pakistan, Indonesia, the Philippines, Russia, Ukraine, Egypt, Ethiopia, Niger, Nigeria, Ghana, Senegal, Afghanistan, Tajikistan, and Zambia. 14 of these programs are implemented as part of the GAIN-UNICEF Universal Salt Iodization (USI) Partnership Project. There were originally 13 Partnership Project programs, but Russia and Ukraine are ending early, and GAIN is adding a program in Nigeria instead. Similarly, UNICEF is adding programs in Sudan and Madagascar. GAIN’s two target countries outside the Partnership Project are Afghanistan and Tajikistan. GAIN provided a small amount of support to Zambia (project closed in March 2014).” GiveWell's non-verbatim summary of a conversation with Rizwan Yusufali, June 19, 2014. • 7. “There were originally 13 Partnership Project programs, but Russia and Ukraine are ending early, and GAIN is adding a program in Nigeria instead.” GiveWell's non-verbatim summary of a conversation with Rizwan Yusufali, June 19, 2014. • 8. GAIN presentation for GiveWell, Pgs 3-4 • 9. "A business model to assure a sustainable supply and distribution of potassium iodate (KIO3)has been established and is beginning to gain traction. During the reporting period, the CIDDP procured 50MT of KIO3 through the GAIN Premix Facility using the project revolving fund with 100% cost sharing from salt producers." GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 5), Pg 2. • 10. “A final report of National Micronutrient Survey was disseminated on February 17, 2013. UNICEF and GAIN provided technical and financial support jointly. The report provided updated estimates of national iodized salt coverage in Bangladesh as well as data about the iodine status of women of reproductive age and school age children disaggregated by rural,urban and urban slum and by wealth index (data have yet to be included in the UNICEF global database on HHIS coverage).” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 5), Pgs 2-3. • 11. “The Partnership advocated with the Government for endorsement of the revised salt law and for more rigorous legislative enforcement for production and marketing of iodized salt.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 3. • 12. “Currently, the draft Salt Law is posted on the GOB website for all stakeholders’ feedback. Government is aiming to submit a revised draft Salt Law to the Cabinet by early next quarter.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 3. • 13. “Project has short listed small and medium scale salt producers based on production capacity. In order to strengthen the QA-QC system. GAIN has engaged a quality control expert in Bangladesh who is reviewing existing materials and supports 15-20 salt producers using the global manual as a reference point. The work also includes working with the targeted salt producers to adopt and put the guidelines into practice within the next year. The Partnership supported the collection of salt samples from all short listed mills at production on a monthly basis in coordination with the CIDD Project and testing at CIDD lab. More than 650 salt samples have been collected each month from all short listed mills and tested at CIDD laboratories situated at eight salt zones. 15 to 20% of collected samples have been validated at Institute of Public Health Nutrition (IPHN) laboratory to ensure accuracy of analysis.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 3. • 14. “The Partnership is supporting GOB in the implementation of a Retailer Rapid Test Kit (RTK) strategy in several districts covering more than half a million people. This work entails the following objectives: • Ensuring accountability of Local Government for monitoring the salt market in the district • Ensuring the involvement of Ward Development Committees for demand creation and monitoring of iodine adequacy at community level • School orientation for promoting salt testing at household level • Establishing the role and responsibility of retailers in meeting community demand through selling adequately iodized, salt using Rapid Test Kits • Retailers are sensitized and trained on use of RTK so that they buy only iodized salt from wholesalers and sell only iodized salt. In this project, communities will be sensitized through the orientation of adolescent school children using locally contextualized media.” • 15. “An audio-visual Mass Communication Package has been launched to improve awareness on the consequences of iodine deficiency and to promote use of iodized salt by consumers. A Docu-drama and a thirteen-episode TV serial on iodine nutrition have been televised through public TV channels.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 4. • 16. 2004-2005: "The median UIE was 163 μg/L in children and 140 μg/Lin women." Yusuf et al 2008, Pg 623. 2011-2012: “However according to median urinary iodine concentration, which was above the cut-off for defining the deficiency (100 µg/l), indicated that Bangladesh as a whole on the total population basis was iodine sufficient, despite the fact that the trend in iodine deficiency prevalence was on rise. The median urinary iodine concentration in the school age children and the NPNL [non-pregnant, non-lactating] women were 145.7 µg/l and 122.6 µg/l respectively.” Bangladesh National Micronutrient Survey (2011-2012), Pg 13. • 17. “The prevalence of iodine deficiency as measured by the proportion of the school age children whose mean urinary iodine concentration was below the cut-off mark of 100 µg/l was 40.0%. It appeared to have a rising trend from the 2004/5 data when it was 33.8%. In the NPNL women, the prevalence of iodine deficiency was 42.1%,which also has shown a rising trend from the earlier data when it was 38.0%.” Bangladesh National Micronutrient Survey (2011-2012), Pg 13. • 18. "Although the median UIC is a good population indicator of iodine status, the distribution of UIC around the median in iodine surveys is often misinterpreted in an attempt to define the number of individuals who are deficient. A common mistake is to assume that all subjects with a spot UIC <100 mg/L are iodine deficient. But dietary iodine intake and therefore UIC are highly variable from day to day. In iodine-sufficient countries where most iodine intake comes from iodized salt, UIC (both spot and 24-h urine collections) show an individual day-to-day variation of 30–40% (Figure 3a,b). Therefore, in an individual whose average daily iodine intake is adequate to maintain normal thyroidal iodine stores, iodine intake will show wide daily variation that will result in many individual days when a UIC value will be less than adequate. Thus, even in populations in which iodized salt ensures adequate thyroid stores, there will nearly always be individuals with a UIC<100mg/L on the day of the survey, but they are not truly iodine deficient. This common error in UIC interpretation was unfor- tunately indirectly endorsed by WHO. When pushed to define the number of individuals with low iodine intakes in order to give prevalence estimates, WHO made the decision to classify all children in iodine surveys with a spot UIC <100 mg/L as having low iodine intakes. This allowed WHO to generate regional and global prevalence data, but the approach also led to the apparent paradox that a country like Switzerland, with a model iodized salt program, a national median UIC of 120 mg/L and a GR of <3% in SAC, is classified as having 'optimal' country iodine status, but at the same time 36% of the population is classified as having inadequate iodine intake." Zimmerman and Andersson 2012, Pgs 558-559. • 19. 2004-2005: “The survey population comprised of boys and girls aged 6-12 years old and women aged 15-44 years old.” Yusuf et al 2008, Pg 2. 2011-2012: “STUDY POPULATION: The pre-school aged children (pre-SAC; 6–59 months old), the non-pregnant non-lactating women of reproductive age (NPNL, 15–49 years of age), and the school-aged children (SAC; 6–14 years old)” Bangladesh National Micronutrient Survey (2011-2012), Pg 17. Pg 19 notes that NPNL women and school aged children were included in the sample for urinary iodine excretion. • 20. 2004-2005 survey: “Nationally, 81.4% of household salt was iodized (iodine content ≥5 ppm), and 51.2% of household salt was adequately iodized (iodine content≥15 ppm).” Yusuf et al 2008, Pg 4. 2011-2012 survey: “About 80% of the households used iodized salt (iodine level >=5 PPM), while 57.6% of the households used adequately iodized salt (iodine level >=15 PPM).” Bangladesh National Micronutrient Survey (2011-2012), Pg 13. • 21. Data from Bangladesh Salt Iodization Information System. Summarized in Data from Bangladesh Salt Iodization Info System. • 22. “Potassium iodate has been supplied without charge to salt producers in Ethiopia over the past few years. Donations were made to the Federal Ministry of Health (FMoH) by donors and implementing partners such as UNICEF, MI and GAIN.” Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia, Pg 5. • 23. “On the one hand the financial donations for the program are being reduced rather dramatically as the world is confronted with many different humanitarian challenges coupled with a nearly global financial crisis. Furthermore, the Tsunami that caused the Fukushima (Japan) nuclear disaster immediately caused the price of KIO3 to increase substantially from US$28/kg to US\$60/kg. This dramatic hike placed severe strains on the USI program.” Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia, Pg 5.

“Past donations have been made under the condition that a self-sustained system will be introduced as soon as possible and donations served to bridge this period.” Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia, Pg 10.

“Donor based financing of the KIO3 supply is not sustainable. Furthermore there is reluctance to ship large amounts of KIO3 into the country, when in the past, this precious mineral had to be shipped out because it expired.” Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia, Pg 21.

• 24.

“GAIN conducted a mission to Ethiopia from 11-20 June 2012 in order to investigate the best options for establishing a revolving fund system for the sustainable supply of potassium iodate (KIO3).” Design and Implementation of a Revolving Fund System for the Supply and Delivery of Potassium Iodate in Ethiopia, Pg 1.

• 25.

“GAIN developed a financially viable approach for the establishment of supply models with integrated cost recovery and distribution to ensure a stable and quality supply of KIO3… GAIN completed national supply assessments of KIO3 in Ghana and Ethiopia reviewing annual demand, capacity to iodize, current donations and subsidies, and existing procurement and distribution arrangements. GAIN then tailored revolving fund models with proposed mechanisms to: accurately forecast demand; appropriately recover proceeds from sales to replenish stocks from approved KIO3 suppliers; and effectively distribute stock. Two hosting institutions were identified, i.e. the Environmental Processing & Associates Ltd (EPA) in Ghana and the Pharmaceutical Fund and Supply Agency (PFSA) in Ethiopia.” KIO3 supply center brief.

• 26.

“Equipment: Procurement of Iodizing machines, generators and other equipment.” GAIN presentation for GiveWell, Pg 7.

“QA/QC: QA/QC testing devices procured for government staff and producers.” GAIN presentation for GiveWell, Pg 7.

• 27.

"Training was given to 12 salt producers on salt iodization process, machine handling and preventive maintenance by the technicians who installed the machines. In addition, practical training was given to the salt producers on quality monitoring of iodized salt using WYD iodine checker. Demonstration of WYD calibration method using reagents and testing of iodized salt was conducted during the training.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 15.

• 28.

"Two salt iodization machines by UNICEF and one Davey salt iodization machine by GAIN were installed at God-Usbo salt production site in Somali Region. The mounting and installation of the machines was conducted from 4th to 6th June 2013. With the contribution of salt producers, shelters were built for the machines using locally available materials. This makes the number of machines in Somali Region four including the one offered by UNICEF in 2008.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 15.

• 29.

“The consultant was contracted design a training course and then travel to Ethiopia from the 9th of May 2012 to the 13th of May 2012 to train officers of the Ethiopian Food, Medicines and Health Care Administration and Control Authority (EFMHACA) and of the Ethiopian Health & Nutrition Research Institute (EHNRI) on the use and maintenance of WYD Iodine Checkers… In all, there were fourteen (14) participants.” Training of Trainers in Use and Maintenance of WYD Iodine Checkers - Ethiopia, Pg i.

• 30.

Ethiopia Indicator Matrix, Sheet PerformanceMonitoringFramework, Cell K10 notes that the baseline data is from Ethiopia’s 2005 National Micronutrient Survey.

• 31.

“(b) The 2014 update for Ethiopia is based on draft results from titration analysis of salt samples collected during the first phase of the 2013-14 Ethiopia National Micronutrient Survey (10% of all households to be included in survey).” GAIN-UNICEF USI Partnership Project Annual Report - without financials (Year 6), Pg 19.

• 32.

National Level activities

Intense sensitization of national level policy makers like Salt Commissioner of India, officials in Ministry of Health and Family Welfare (MoHFW) viz. Secretary, MoHFW; Joint Secretary (RCH), MoHFW; officials from Ministry of Commerce and Industries, and officials in Food Safety and Standards Authority of India, officials in the Ministry of Railways was undertaken. ICCIDD took up the concerns of the salt producers and traders with Salt Commissioner and other officials from the Salt Department. ICCIDD also facilitated the participation of Salt Department officials in meetings with traders and producers in Bihar, Gujarat and Tamil Nadu.

State Level Activities

ICCIDD and state focal persons undertook a series of activities viz. sensitization meetings with policymakers in Ministry of Health, Department of Food and Civil Supplies, Salt Trading Corporations, salt producers, traders and other partner organizations. Advocacy meetings were organized with Health Department officials and officials from Department of Food and Civil Supplies in all five states, with officials from Tamil Nadu Salt Corporation and Tamil Nadu Civil supplies Corporation in Tamil Nadu, and Rajasthan Civil Supplies Corporation in Rajasthan.” Strengthening the supply chain of iodized salt through national and state level activities - India, Pg 2.

• 33.

“Supply chain of the iodized salt was considered as one of the weakest link in terms of monitoring and is vital in terms of ensuring the quality of iodized salt in the country. A project was launched by ICCIDD in five high priority states in support with GAIN in April 2013 to strengthen the supply chain of iodized salt… Intense sensitization of national level policy makers like Salt Commissioner of India, officials in Ministry of Health and Family Welfare (MoHFW) viz. Secretary, MoHFW; Joint Secretary (RCH), MoHFW; officials from Ministry of Commerce and Industries, and officials in Food Safety and Standards Authority of India,officials in the Ministry of Railways was undertaken. ICCIDD took up the concerns of the salt producers and traders with Salt Commissioner and other officials from the Salt Department. ICCIDD also facilitated the participation of Salt Department officials in meetings with traders and producers in Bihar, Gujarat and Tamil Nadu.” Strengthening the supply chain of iodized salt through national and state level activities - India, Pgs 1-2.

• 34.

"The National Coalition for Sustained Iodine Intake, jointly supported by UNICEF and GAIN, continued to hold stakeholders meetings on a regular basis and carried out high level advocacy towards NIDDCF.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 22.

• 35.

"UNICEF and GAIN enhanced its advocacy efforts to increase the availability and accessibility of iodized salt in the states. Various meetings and workshops were held at national and state levels to highlight the progress achieved, discuss future plans to overcome challenges, and to catalyze expansion of adequately iodized salt by engaging salt producers and traders. Intense sensitization of national and state level policy makers was carried out including the Salt Commissioner of India and high level authorities in the Ministry of Health and Family Welfare, Ministry of Commerce and Industries, Ministry of railways, Ministry of Food and Civil Supplies, and the Food Safety and Standards Authority." GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 22.

• 36.

"UNICEF and GAIN facilitated the constitution of state USI Coalition in various states. A State USI Coalition under the State Health Departments were newly formed in Bihar and Gujarat. In Uttar Pradesh, a technical sub-committee of the state USI Coalition was established which is working towards the constitution of state USI Coalition. In Tamil Nadu,a multi-stakeholder meeting on USI under the chairmanship of Director General of Health Services endorsed the formation of the state USI Coalition. The overall objective of the state USI Coalition is to ensure effective coordination and synergy among all stakeholders and key government departments involved in the USI Program.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 22.

• 37.

"The Partnership is helping to expand the supply of adequately iodized salt through advocating to the Government to encourage the natural consolidation of the salt industry… GAIN has conducted a research scoping of setting up a National salt marketing cooperative federation.” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 6), Pg 25.

• 38.

“Salt MIS deployment need assessment and decision to implement was carried out by GAIN to investigate IT intervention as a possibility to enable salt department to have quick information available related to salt production and quality compliance, which is actionable and would aid the resources within department to further their objective of USI... The feasibility study clearly revealed that Salt Department’s ability to respond to its business requirements was critically impaired due to lack of timely information and communication availability… VBSOFT India Limited along with ICCIDD undertook the solution development and deployment activity. A thorough study and close interaction with the stakeholders enabled VBSOFT to develop the software as per the requirements of the salt department including business process reengineering to enable MIS delivers intended efficiency and information… Hence in year 2013, GAIN funded implementation of capacity building program for salt department through VBSOFT & ICCIDD.” Salt Management Information System - India, Pgs 1-3.

• 39.

“100% Factory Data available against 70% in year 12-13… 213 active Users – comprises of all officers and executives.” Salt Management Information System - India, Pg 4.

• 40.

“A 3 day hands on training workshop on ‘Quality Assurance for the iodine content of salt in the laboratories of Salt Department, India’ held at Gandhidham, Gujarat from 28th August to 30th August, 2009… Training workshop held for chemists of all laboratories of Salt Commissioner Department. Workshop attended by Salt commissioner and all deputy and assistant salt commissioners.” Consultant work status report - India (October 2010).

• 41.

“Monthly reports for month of February, April and May 2010 have been received and submitted to GAIN.” Consultant work status report - India (October 2010).

• 42.

“The next session started with lecture by Dr Madhu Karmarkar on Iodine metabolism and main aspects of iodine deficiency in humans. The next lecture was on methodology to be used in estimation of iodine in iodised salt with elaboration of each step. Dr Karmarkar also elaborated on the equipment to be used… The morning session of 2nd day started with practical exercise. Participants were divided into 5 groups as per the pre-determined nodal laboratory groups. This exercise was done to acquaint each participant with the proper methodology to be used in estimation of iodine in iodised salt as well as for preparation of known value sample for establishing internal quality assurance program in each laboratory… This session was followed by presentation from two scientists from CSMCRI, Bhavnagar regarding Atomic Absorption Spectrophotometry and iodine and iodate determination in table salt by ion exchange chromatography followed by practical demonstration of use of Atomic Absorption Spectrophotometer… On second day afternoon session and third day morning session was spent in discussing the details of external quality assurance program with elaborate discussion on exchange of samples between participating, nodal and reference laboratories along with the precautions to be taken in each step… The third day morning session started with lecture by Professor Chandrakant S Pandav. The topic was lessons learned from earlier experiences in IDD.” Consultant work status report - India (October 2010), Pgs 6-7.

• 43.

“Reporting templates for internal quality and external quality assurance were developed.” Consultant work status report - India (October 2010), Pg 2.

• 44.

“An inventory of chemicals, reagents and equipments at laboratories under Salt Commissioners made. Existing gap were identified and appropriate suppliers/vendors selected. The laboratories under the Salt Department were equipped with necessary (only gap supply) chemicals, reagents and equipments.” Consultant work status report - India (October 2010), Pg 2.

• 45.

“Visits to 5 nodal laboratories by the Consultant from ICCIDD Reference laboratory made. Refresher training on Quality assurance was provided once again during these visits. On site inspection of the QA/QC protocols being followed at these laboratories were reviewed and corrective measures suggested.” Consultant work status report - India (October 2010), Pg 2.

• 46.

"Manual on best practices for QA/QC in salt iodization processes developed by global team of GAIN, in collaboration with Intertek-ICCIDD, was presented to Salt Commissioner and industry representatives” GAIN-UNICEF USI Partnership Project Annual Report - Annex 1: Country Progress (Year 5), Pg 13.

• 47.
• 48.
• 49.

“All children aged 12-23 months and women who delivered during 12 months preceding the survey in the urban and rural areas inthe country formed the two universes of the study.” UNICEF India Coverage Evaluation Survey (2009), Pg 5.

• 50.

“Salt was tested for iodine content by the interviewers at the household level. Overall,71.1 percent of the households were using cooking salt which was found to be iodized at the recommended level of 15 ppm or more. Only 9.3 percent of the households used salt that was not iodized at all and 19.3 percent used salt that was iodized inadequately (UNICEF India Coverage Evaluation Survey (2009), Pg 152.

Methodology described on Pgs 5-12.

• 51.

India Indicator Matrix, Sheet PerformanceMonitoringFramework, Cells L10:M10.

• 52.

“In NFHS III there were eight states where the consumption of iodized salt was listed as much below average as compared to the rest of the country. In 2010, the Salt Commissioner, Micronutrient Initiative, UNICEF, WHO and GAIN held consultations on the situation of the use of iodized salt across the eight states in India and decided to commission a new study in order to estimate use of rural household level iodized salt in eight states in India. The household level iodization level in these states was lower than the national average during NFHS III (2005-06) and total population of these states put together was more than 50.5% of the country population…
The study was conducted across eight states of Rajasthan, Uttar Pradesh, Uttarakhand, Madhya Pradesh, Orissa, Andhra Pradesh, Tamil Nadu and Karnataka. India in 2010 by AC Nielsen at rural households and retail / wholesale sellers of salt.” Iodized Salt Coverage Study Conducted Across Eight States in India (2010), Pg 5.

• 53.

“The use of iodized salt at the rural household level has increased across all states. It has gone up from 27% to 47.2 % compared to NFHS 3.” Iodized Salt Coverage Study Conducted Across Eight States in India (2010), Pg 8.

• 54.

Rah et al 2013, Pg 8.

• 55.

Examples:

• “Associate was able to conduct a monitoring visit (see attached travel report) in Bacolod and Batangas and instructed both warehouses on the use of the QAQC software.” (Pg 2)
• “[Factory name] – a smaller pump had been procured and turned over to Salinas Pangasinan. A monitoring visit to the Salinas Batangas was conducted. The target iodization levels were within FDA standard but the standard deviation was high. Recommendations to improve were given.” Philippines activities (December 2013 to July 2014), Pg 4.
• “[Factory name] – no regular recording; compressor, not dosing pump is being used; Warehouse was given 2 weeks to use the dosing pump and do recording (This deficiency was corrected by Cebu with support from DOST; However, while most iodine levels passed standard, significant number failed and control seemed erratic; Factory performance will be under close observation.” Philippines activities (December 2013 to July 2014), Pgs 6-7.
• ”Associate conducted monitoring of [factory name] and [factory name] factories (see attached mission report). There are indications that [salt company name] had issued a company-wide order to lower iodization levels to below 20ppm. This highlights the importance of fast-tracking strengthening of FDA regulations of the salt industry.” Philippines activities (December 2013 to July 2014), Pg 8.
• 56.

“Associate conducted monitoring of [factory name] and [factory name] factories (see attached mission report). Discrepancies were noted in QAQC implementation, equipment management and reporting. Iodization levels were below 10ppm and there seem to be no urgent effort to improve. Associate recommended to DOST to suspend QAQC certification of Artemis until the issues are addressed.” Philippines activities (December 2013 to July 2014), Pg 8.

• 57.

“2 dosing pumps broke down in Cebu and Batangas. Associate sent 2 service pumps and requested to collect the broken down pumps for inspection by the distributor.” Philippines activities (December 2013 to July 2014), Pg 2.

• 58.

“WYD Training for Region CAR set for August 14. 6 WYDs (3 fr GAIN, 3 fr UNICEF) will be provided.” Philippines activities (December 2013 to July 2014), Pg 14.
WYDs are referred to as “iodine checkers” elsewhere in the document.

• 59.

“Annual technical meetings among ITDI-DOST… The program for the national meeting is finalized and budget had been requested from GAIN HQ.” Philippines activities (December 2013 to July 2014), Pg 14.

• 60.

“Provision of start-up fund to the ITDI employees association who will produce and sell WYD reagents – Accomplished.” Philippines activities (December 2013 to July 2014), Pg 16.
“Development of supply system for the procurement of replacement WYDs and Dosing Pumps – Partially accomplished.” Philippines activities (December 2013 to July 2014), Pg 16.

• 61.

“UNICEF supported the DOH soft launch of the Sangkap Pinoy Seal (food fortification seal) for the adequately iodized salt. This was led by Asst. Secretary Tayag and attended by the UNICEF Deputy Country Representative Alim and FDA Director General Go. UNICEF and GAIN Associate sees this as a unifying strategy for regulatory and promotional activities. The FDA, using the seal guidelines (and the licensing checklist), will conduct inspection of salt factories to see which would be awarded the seal (meaning they have the capacity and are iodizing within FDA standards). A series of information campaigns and or meetings are planned with the big producers and repackers to encourage them to have the seal. The seal project will be promoted to the regional task forces and the LGUs and association of supermarkets so that they will promote availability of only salts with the seal in their markets. The seal will also be promoted to the consumers through mass media and the health system. UNICEF and GAIN will put much effort behind this initiative in the next months…
Associate presented draft plan to launch the SPS seal.” Philippines activities (December 2013 to July 2014), Pgs 18-19.

• 62.

“Support to Cagayan Valley region to develop a system integrating the WYD Iodine Checker in their checkpoints and/or in their regional regulatory monitoring… Support to Occ. Mindoro to develop a system integrating the WYD Iodine Checker in their monitoring of outgoing salt from the San Jose ports…
Associate conducted monitoring visit last April 9-12 (see attached travel notes). The two most important checkpoints had been verified to be functioning. One LGU has yet to determine the location of its checkpoint among two options. One checkpoint was determined to be as not too critical so WYD be be assigned to NNC region to test samples from different locations to validate effectiveness of the checkpoints. Despite being functional (and reports of shipments being turned back), many of salt samples collected by the Associate were below FDA standard. Associate is requesting for a review with NNC region.” Philippines activities (December 2013 to July 2014), Pgs 20-22.

• 63.

Philippines case study, Pg 5.

• 64.

“GAIN’s current program portfolio promotes USI in 16 countries.” GiveWell's non-verbatim summary of a conversation with Rizwan Yusufali, June 19, 2014.

• 65.
• “(a) As for the Year 5 report, no baseline data were available for inadequately iodized salt; therefore it is unclear whether the figures for China (7.1%) and Pakistan (83.0%) correspond to inadequately- or non-iodized salt. These data are therefore presented here as non-iodized salt.

(b) The 2014 update for Ethiopia is based on draft results from titration analysis of salt samples collected during the first phase of the 2013-14 Ethiopia National Micronutrient Survey (10% of all households to be included in survey).

(c) Ghana updated data for inadequately iodized salt since last year's report. Based on a re-analysis by UNICEF of titration data for the sub-sample of households from the 2011 MICS - using 5ppm as the cut off for no additional iodine added, and including households where no salt was available as HH with non-iodized salt, assuming the same proportion for the titration sample as found in the national sample. Adapted from UNICEF Ghana report on the titration results.

(d) India updated data for adequately iodized salt in 2013-14 is an estimate based on data from the Salt Department for iodized salt production combined with results of quality control checks (78% according to MIS reports 2013-14), supported by data from the National Rural Health Management system reporting results from retail salt samples for iodine in at least half the districts nationally during the period 2012-13 (93% met standards using rapid test kits).

(e) Niger data updated from last year. Reanalysis of the titration data from the 2012 DHS, including HH with no salt as HH with non-iodized salt, assuming the same proportion in the sample for titration as found in the national sample for rapid test kit reported for the 2012 DHS.

(f) Senegal updates from 2010-11 EDS-MICS adapted to include HH with no salt as HH with non- iodized salt. The 2012 SMART survey reported 57.7% any iodine (by RTK), in agreement with the findings from 2010-11.”

GAIN Email from Greg S. Garrett, October 8th, 2014

• GAIN adds that “[the] baseline and updates only give a general idea of trend and can rarely be directly compared. In only 3 of the 9 countries (Bangladesh, China and Indonesia) was the methodology for analysing iodine content the same (quantitative) at baseline and update. In Ethiopia, Ghana, India, Niger and Senegal the baseline was from rapid test kits results and the update based on titration. In Pakistan, it was the reverse” GAIN Email from Greg S. Garrett, October 8th, 2014
• “Data sources (Q = quantitative, S = semi quantitative)
Bangladesh baseline (Q) – National iodine survey 2004-5
Bangladesh update (Q) – National Micronutrient Survey 2011
China baseline (Q) – National IDD Surveillance Report 2006
China update (Q) - Brief Official USI Monitoring report 2011
Ethiopia baseline (S) – Final Report DHS 2005
Ethiopia update (Q) – Pre-Micronutrient Survey - MN Forum 2014
Ghana baseline (S) – MICS 2006
Ghana update (Q) – MICS 2011 (sub-sample by titration)
India baseline (S) – Coverage Evaluation Survey 2009
India update (Q) – MIS data on iodised salt production and quality control 2013-14
Indonesia baseline (Q) – National Heath Research Survey (Riskesdas) 2008
Indonesia update (Q) - National Heath Research Survey (Riskesdas) 2013
Niger baseline (S) – DHS 2006
Niger update (Q) – DHS 2012 (re-analysed)
Pakistan baseline (Q) – National Nutrition Survey 2001-02
Pakistan update (S) - National Nutrition Survey 2011
Senegal baseline (S) – DHS 2005
Senegal update (Q) - 2010-11 EDS-MICS” GAIN Email from Greg S. Garrett, October 8th, 2014
• 66.
• 67.

“(b) The 2014 update for Ethiopia is based on draft results from titration analysis of salt samples collected during the first phase of the 2013-14 Ethiopia National Micronutrient Survey (10% of all households to be included in survey).” GAIN-UNICEF USI Partnership Project Annual Report - without financials (Year 6), Pg 19.

• 68.

See footnote above that details notes (a) through (f) in the chart. Also: “Rather than administering new iodine surveys at the beginning of its programs, GAIN used the most recent data collected prior to the beginning of the programs in 2008-2009. These data are widely accepted as the baseline data.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Rizwan Yusufali, May 19, 2014.

• 69.

GAIN presentation for GiveWell, Pgs 3-4.

• 70.

“To date, as such cost per beneficiary will go down as we achieve greater reach over total grant period.” GAIN presentation for GiveWell, Pg 3.

• 71.

"GAIN and UNICEF were jointly funded by the Gates Foundation to reduce iodine deficiency
through the Universal Salt Iodization (USI) Partnership Project, which will end in 2015." GiveWell's non-verbatim summary of a conversation with Greg Garrett and Jonathan Gorstein, April 30, 2014, Pg 3.

• 72.

“GAIN wants to continue supporting national USI programs following the completion of the
Partnership Project. In addition to the countries that the USI Partnership currently works
in, GAIN wants to support iodine programs in some smaller countries in Africa and Asia.
GAIN hopes that continued funding for iodine programs comes from bilateral aid
organizations such as the European Commission, the UK Department for International
Development (DFID), and USAID. Despite attempts to diversify the funding base for USI, additional money is needed to ensure full scale up and sustainability. GAIN is developing
sustainable, market-based plans for future salt iodization in over 10 countries. Other
countries, such as Senegal and Ghana, likely need a more subsidized model to support
iodization programs. GAIN is currently determining the costs of these plans.” GiveWell's non-verbatim summary of a conversation with Greg Garrett and Rizwan Yusufali, May 19, 2014.

• 73.

“GAIN has very little unrestricted funding. All of the funding for GAIN’s various nutrition
programs is specifically allocated to those programs, rather than being funded by GAIN’s
unrestricted funds.” GiveWell's non-verbatim summary of a conversation with Rizwan Yusufali, June 19, 2014.

• 74.

“While GAIN has provided some support to the USI in Zambia, we frequently don’t include it as a USI program country because our level of support was small and the project was also utilizing some funds we already had in country on large scale fortification.” Rizwan Yusufali, email to GiveWell, July 16, 2014.