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Fortification
Universal Salt Iodisation in Africa:
Road to overcoming the last hurdles
Review
Over 330 million people remain at continued risk of Iodine
Deficiency Disorders (IDD) in Africa. The spectrum of Iodine Deficiency
Disorders including cognitive and mental impairment can be prevented by
sufficient intake of iodine through the diet. Iodisation of salt has been
proven to be the most effective strategy to provide populations with iodine and
prevent IDD. Iodizing all salt can prevent more than 12 million cases of mental
impairment in infants annually.
 It is reported that 66% of African households consume
adequately iodized salt, but this hides significant disparities. At the country
and community levels, the number of people consuming adequately iodized salt
ranges from 2% to 98%. 260 million people in Africa have insufficient iodine
intake resulting in iodine deficiency rates which are associated with a 10% to
15% lowering of the average intellectual capacity. These statistics only show
the tip of the iceberg, it is postulated that iodine deficiency disorders will
negatively influence achievement of 5 out of the 7 millennium development goals
by developing nations.
In spite of many successes, it is clear that more needs to be done
to achieve Universal Salt Iodisation (USI) in Africa. Progress in this area has
stalled over the last decade and the causes and bottlenecks have to be analyzed
in order to address these remaining challenges. The strategies and approach
used to achieve success with USI programs so far may also need to be reviewed
and adapted accordingly.
In an effort to identify key gaps that are limiting progress
towards achievement of USI, the Micronutrient Initiative, commissioned a series
of salt assessments in 2005.1 These assessments were conducted in 10 main salt
producing countries in Africa: Ghana, Senegal, Ethiopia, Mozambique, Angola,
South Africa, Namibia, Botswana, Tanzania, and Sudan. The salt produced in
these countries has a wide reach and potential to make the greatest impact on
coverage of iodized salt.
The main aim of the assessment missions was to map the flow of
salt across the sub-continent and to identify key bottlenecks and challenges
which have prevented achievement of USI so that they can inform strategies to
accelerate progress. These findings are also guiding MI’s ongoing work on
Universal Salt Iodization, including a new partnership with the World Food
Programme. This new partnership aims to strengthen local salt producers’
ability to iodize salt in 6 countries where iodine deficiency rates are high
including the African countries Sudan, Ghana, and Senegal. The six countries of
focus are home to over 40 percent of the world’s population not yet
protected against iodine deficiency.
The main issues uncovered and a summary of the mapping and
assessment missions are presented here starting with an analysis of the salt
supply across the Sub-Saharan region.
We need to work with large, medium and small producers across
the region to ensure that all salt for human and animal consumption is
effectively iodised. Salt exporters and importers should accept iodised salt as
the only norm. Leakages of non iodised salt across markets and border need to
be plugged.
Venkatesh Mannar,
President, Micronutrient Initiative
Salt Supply across Sub Saharan Africa
The map below shows the main sources and the flow pattern of salt
across Africa overlapped with the proportion of households consuming iodized
salt (coverage). Comparison of the two layers in the figure clearly illustrates
that the salt supply and proportion of salt that is iodised by supplying
countries has a direct correlation with households consuming iodised salt.
The diagram provides a compelling argument of why we should target
salt iodisation programmes in countries that produce salt in order to meet and
sustain USI goals. Although a wide range of factors contribute to low iodized
salt coverage, supply and therefore availability of iodised salt was found to
be a key factor needing attention.
Targeting salt producing countries would enable better use of
resources
- Resources will not be wasted in non salt producing countries
and monitoring and enforcement programs can also be streamlined to focus on
fewer countries.
- Iodisation integrated into salt production would lead to
increased supply and access to iodized salt by populations. This way,
awareness-creation activities (demand) are complemented by availability
(supply).
The analysis of the findings from the missions identified several
bottlenecks that stall progress towards accelerating USI efforts. The mission
findings are discussed below; they cover the identified bottlenecks and the
proposed strategies which could be used to guide USI programs across
Africa.
Salt Supply and Enhancing Production of Iodised Salt
The success of USI is influenced by ensuring the continuous
availability of iodized salt. Sustained iodized salt production and supply will
result in higher coverage of iodized salt and potentially prevent more than 12
million cases of mental impairment in infants annually.
The Salt Trade: how it works…
The larger producers are able to supply salt in larger quantities
and on a regular basis as they can produce and distribute their salt at a lower
cost. They also have access to formal transportation routes to export bulk
quantities of salt to other countries. This makes the price of their salt more
competitive than that produced by subsistence producers. This has a tendency to
leave the smaller producers with the only option of competing in localized
markets or find ways to cut costs in order to remain competitive. Unfortunately
the decision to not iodize salt is frequently the easiest option for small
producers to cut costs and remain competitive.
In countries with many small scale salt producers such as Senegal,
Ghana and Mozambique, traders normally form a critical link and can be either
an opportunity or a major bottleneck. Small producers typically will not have
access to finance or capital preventing them from integrating iodisation into
their business and participating in markets where their product is valued
better. In such situations, traders who have access to these markets and
capital are placed in a stronger position to set prices and apply pressure on
smaller producers to reduce their margins. This drives small scale producers to
cut costs and impedes growth and reinvestment into the business. This usually
comes at the expense of iodisation, especially where enforcement of iodisation
is weak.
Salt Iodisation programs will have to include support beyond
adding iodine to salt, provision of equipment and potassium iodate and social
awareness campaigns in order to address the remaining challenges with USI. The
support will have to include innovative business solutions, improving access to
markets, micro-financing and improvement in overall productivity and efficiency
within the industry.
Appropriate Salt Iodisation Technology
 From a purely technical point of view, integrating
iodisation into salt production requires two additional components; iodisation
equipment and potassium iodate. Although there has been extensive equipment
donation and potassium iodate provision to accelerate USI programs, examples of
such support not being effective outnumber where it was effective. Some of the
key lessons learnt in each area are discussed below.
Equipment: It is critical that appropriate iodisation equipment
and technology is applied. Equipment that is seen in the field is frequently
sitting idle, rusted or scavenged for parts. These units were not used because
they were not designed for the capacity of the salt works and did not take into
account the movement and handling of salt within the salt facility.
One size fits all’ units in any process industry do not work
and closer attention has to be paid in designing and providing equipment so
that it integrates with the operations and does not result in the salt
producers having to bear excessive costs and undertake extra handling of
salt.
 Other observations were that equipment support was not backed up by
on site training in the use and maintenance of the equipment, and there was a
lack of spares and parts for regular service and of follow-up support. In a few
cases, equipment support has also included cement mixers and drum mixers, these
units are not designed for use with salt and corrode quickly or require too
much effort in iodizing salt in terms of excessive handling.
Potassium iodate: Potassium iodate is commonly used as a
fortificant for salt iodisation. Free or subsidized provision of potassium
iodate may in some cases be the only immediate solution. Small producers may
not have the cash flow to procure potassium iodate and would typically have to
import since it is only produced in a handful of countries. The main issue that
needs to be addressed however is access to potassium iodate within close
proximity to salt producers and in smaller quantities. USI programs will have
to address this together with overall profitability and effective enforcement
in order to ensure that salt producers sustain iodisation when subsidies are
removed.
Smaller Producers - the important link
Small producers who form collectives are more likely to make their
business more profitable. Collectives are able to produce higher volumes of
salt and take advantage of economies of scale, and they can absorb price
deviations and cope with variations in market trends better compared to small
individual salt producers. As a group they have a better chance of expanding
their market access and receiving support from donors and other developmental
agencies which can gear them for potential sustainable growth and commercially
viability.
This will be achieved when the salt producers are equipped and
supported with business development skills which can be introduced through
effective training and facilitating access regular or continuous support.
Business services training offered can cover a range of topics
including microfinance, branding to differentiate between iodized salt and low
quality non iodized salt, proper packaging and labeling (currently uncommon)
all of which can have an impact on the final selling price and hence
profitability.
Policy Change and Effective Enforcement
 One of the biggest challenges in salt producing countries
is that more resources need to be allocated towards improving infrastructure
(accessible roads and transport). The growth and profitability of the salt
industry is highly dependent on the available infrastructure and salt
iodisation is more sustainable when the salt industry itself is operating in a
sustainable environment. Investment in iodisation equipment and potassium
iodate (fortificant) is more likely to be used effectively and compliance is
also more likely to be high when the industry is competitive and productive.
This is one of the main common traits in countries that have achieved USI
around the world.
It is recognized that Regional barriers to trade also impede on
potential growth in the salt industry. These require attention and need to be
addressed; this is especially seen in West Africa where the trade between
Anglophone and Francophone countries is restricted through economic policies
and therefore limits the marketability of salt being produced in Senegal and
Ghana and in fact fuels import from sources that are remote and more costly
such as Brazil and Namibia.
Governments need to agree on standard iodine levels for salt
iodisation. Common standards can promote salt import and export relations
between countries and also simplify monitoring of salt iodisation.
The taxes and duties levied on the salt industry and not
necessarily iodine or iodisation equipment in many African countries are
choking the industry. Although such policies bring in revenue for Governments,
the longer term returns both from an economic and social perspective are
negative. This is because it contributes to poor sales of salt since the prices
are not competitive in the international market, prevents growth and expansion
within the industry, lowers production and inhibits job creation. All these
reduce potential revenue for Governments. From a development standpoint, poor
performance with prevention of IDD has been well documented to contribute
towards reduced GDP, increased burden on healthcare systems and is linked to 5
of the 8 millennium development goals.
Aggressive political advocacy and commitment from Government is
required to fuel progress. This has to include a commitment from Government in
creating a better environment for the salt industry. This would also encourage
support from developmental programmes like the World Bank and other regional
banks. These partnerships can bring the required investment in infrastructure
development.
It can be done…
The assessment findings indicate that production bottlenecks have
limited progress towards USI and if adequately tackled, improvement in iodized
salt coverage can be expected. Investment in improving supply of iodized salt
has a potential to have the greatest impact on USI and needs to be prioritized
and monitored. Progress in this area can be accelerated if supported by a more
favorable investment environment within the salt industry, effective
enforcement of salt iodisation legislation and development of innovative
solutions addressing the problems faced primarily by the medium and small scale
segment of the industry.
“With a sustained effort and innovation to reach those
that have not yet been reached, salt iodisation can become a universal and
permanent solution to a problem that has limited the progress and potential of
a significant proportion of humanity”
Venkatesh Mannar,
President, Micronutrient Initiatived
Researched and written by Rizwan Yusufali and Thabang Matlhafuna
Micronutrient Initiative.
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