To Overcome IDD:Indonesian Experience

Triono SoendoroMinistry of Health

1. 1979: M.D. (Airlangga Medical School, Indon) 2. 1985-1989: M.Sc, M.Phil, Ph.D, Yale Univ, USA. 3. 1991-2000: Director Health & Nutrition, Bappenas 4. 2000-2001: Leadership Fellow at the Gates

Institute, University of Johns Hopkins, USA5. 2001: Secretary of Decentralization Unit and

Policy Advisory Group to MoH;6. 2001-now: Senior Associate, Bill and Melinda

Gates Institute, Johns Hopkins University, USA 7. 2006-2009: Director General of NIH-RD, MoH; 8. 2009 –now: Senior Advisor to MoH. 9. 1997-now: Faculty Member of O/G, Reproductive

Endocrinology, Med Sch Udayana Univ, Bali.10. 2001-now: Visitng lecturer at several universities.11. 2012- : Assist Indon President to Post MDG 2015

Outline

1. Setting the Objectives2. Assessing IDD Progress3. The Challenges 4. The Way forward

Outline

1. Setting the Objectives2. Assessing IDD Progress3. The Challenges 4. The Way forward

The Objectives

1. To increase the national coverage of adequate iodized salt consumption at household level

2. To sustain the coverage of adequate iodized salt consumption in all districts

5

Outline

1. Setting the Objectives2. Assessing IDD Progress*3. The Challenges 4. The Way forward

Assessing IDD Progress

• IDD surveys: 93, 96/98, ‘03 (TGR, UIE)

• HH’s Iodized Salt: –CBS (Susenas 1998-2003), –MOH (Riskesdas 2007 - 2013)

• Urinary Iodine Excretion (UIE): –Riskesdas 2007 (sub-samples in 30

districts)

IDD Survey: ‘93, ’96/’98, & ‘03 Design ‘93 survey Baseline

(96/98)Evaluation (‘03)

Province 5 27 28

District/City 25 276 343

Sub-district 170 3916 -

Cluster Primary school Primary school Primary school

60 in every province 3 in every sub-district

25 in every district

Palpation of thyroid gland enlargement 

School children 6-10 School children 6-12 School children 8-10

Pregnant women <35 Pregnant women <35

 

School children Pregnant women School children

Urine sample for urinary iodine level

Analysis urine sample: wet acid digestion method using potassium chlorate

Analysis urine sample: wet acid digestion method using potassium chlorate

Analysis urine sample: wet acid digestion method using ammonium persulfate

Pregnant women Pregnant women (in 2 provinces)

-

Progress: IDD Elimination/TGR

80/82 96/980

10

20

30

40

50

III

II

IB

IA

YEAR OF SURVEY

PE

R C

EN

TA

GE O

F S

CH

OO

L

CH

ILD

RE

N S

AM

PLED

Note: Only sub-districts included within the 80/82 sample frame were included from the 96/98 sample for comparison

Progress: IDD Elimination/TGR

80/82 96/98 20030.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

30.0

9.8 11.0

Year of Survey

% T

GR

Sch

ool A

ge C

hild

ren

The Changes: District Endemicity

EndemicityDistrict/City

96/98 03Category TGR N % N %

Non-endemic < 5.0% 123 44.7 148 43.3

Mild endemic 5.0 – 19.9% 106 38.6 122 35.7

Moderate endemic

20.0 – 29.9%

30 10.9 42 12.2

Severe endemic

>= 30% 16 5.8 30 8.8

T o t a l 275 100 342 100

Changes: 268 District Endemicity

EndemicityDistrict/City

1996/1998 2003

Category TGR N % N %

Non-endemic < 5.0% 122 45.5 115 42.9

Mild endemic 5.0 – 19.9% 104 38.9 96 35.8

Mod- endemic

20.0 – 29.9% 28 10.4 35 13.1

Sev- endemic

>= 30% 14 5.2 22 8.2

T o t a l 268 100 268 100

Distribution of Province by Category of Endemicity in ’96/’98

and ‘03

EndemicityProvince

1996/1998 2003

Category TGR N % N %

Non-endemic < 5.0% 9 34.6

7 25.0

Mild endemic 5.0 – 19.9% 13 50.0

17 60.8

Moderate endemic 20.0 – 29.9% 2 7.7 2 7.1

Severe endemic >= 30% 2 7.7 2 7.1

T o t a l 26 100

28 100

Trend of HH’s Iodized Salt Consumption: 1998-2007

1998 1999 2000 2001 2002 2003 20070%

20%

40%

60%

80%

100%

65.2 63.6 64.5 65.4 68.5 73.262.3

15.1 18.0 18.4 16.7 15.4 12.723.7

19.7 18.5 17.0 17.9 16.1 14.1 14.0

Adequate Inadequate None

Source: Susenas 1998-2003, Riskesdas 2007

% HH Consume Iodized Salt: 2003-2007

NTB NTT

Sultr

aJa

tim Bali

Maluk

u

Bante

nJa

bar

Jate

ng

Sulse

l

Sulte

ng DKI

Bengk

ulu

Lam

pung DIY

Riau

Malut

Kaltim

Kalbar

Papu

a

Kalte

ngSu

lut

Sum

ut

Goron

talo

Sum

bar

Sum

sel

Jam

bi

Babel

0

10

20

30

40

50

60

70

80

90

100

2003 2007

% H

ousehold

consum

ed a

dequate

Iodiz

ed s

alt

Association between UIE and Iodized Salt Coverage

Urinary Iodine and Iodized Salt Coverage - Provincial datay = 1.6728x + 123.34

R2 = 0.4727

0

100

200

300

400

0 20 40 60 80 100Iodized salt coverage (%)

Uri

nar

y io

din

e (m

edia

n)

18Source IDD Survey 2003

HH’s Iodized Salt vs Iodine Urine (School Age Children)

Iodized Salt (ppm) UIE ug/L

<5 7,8% <20 0,4

5-15 29,4% 20-50 3,2

15-20 12,6% 50-100 9,3

20-30 25,7% 100-300 65,1

30+ 24,5%** >300 21,9*)

Source: Riskesdas 2007 (30 Districts)

*) Excessive:

Outline

1. Setting the Objectives2. Assessing IDD Progress3. The Challenges* 4. The Way forward

The Challenges• Universal Salt Iodization (USI) targets

have not been met nationally, but excessive iodine intake is beginning to manifest

• Focus of USI should be directed to Provinces/Districts with HH’s consume Iodized salt <50%

• Attention is also needed for areas where the UIE level >300 ug/L

• Health disparities*: PHDI

The Purpose: PHDI

• Describe public health development progress for entire districts in Indonesia

• Focused programs interventions (local specific) in each districts.

PHDI Progress: ‘07-’10 (‘13)

Composite PHDI (7 Indicator): Malnutr, Stunring, Imuniz ANC/MCH, Sanitation, Water

DIYBal

i

Kepri

Bengku

luJatim

Sumut

Sumbar

Jabar

Sumse

l

Jam

bi

Kalbar

Bante

nNTB

Pabar

Goron

talo

NTT

Maluku

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

indeks 2007

indeks 2010

Provinsi

Ind

eks

The Benefits• A tool to evaluate the process of

improving a certain area (district/municipality) on health status over time.

• An advocacy for province and district government to increase their health status using focused resources and programs interventions priority.

• As a criteria of health fund allocation from central to province and district government.

District DBK: The Areas

 Category 2007 2012

• District/Urban DBK 130 156

• District/Urban Non DBK

310 341

Jumlah 440 497

P-DBK: 10 Prov as of ‘11 Aceh (14/21) NTB ( 6/9) NTT (11/16) Sulteng (7/10) Sultra (8/10)

Gorontl (5/5) Sulbar (4/5) Maluku (5/8) Pap Bar (6/9) Papua (14/20)

• Prop DBK: # total : 28 prop 130 kab/kot• Prop > 50% Kab DBK : 10 prop* 80 kab/kot• Prop < 50% Kab DBK : 18 prop 50 kab/kot

27

Sumber : Riskesdas 2007

Training

Actions

Organizational Change

Start End

Actions

RDSRDSTranslation

InternalSupportGroup

Mentoring

Learning History: Cohort of PDBK

The Challenges: Partnership

Comitment & Involvement

District Gorontalo (2011)

Profil 2010

Densus Profil 2010

Densus Profil 2010

Densus Gizburkur

Jumlah Ditimbang Gizburkur IPKM 2007

32,363 32,045

23,300

28,458

969 3,286

9,187

sejumlah

The Way Forward

• Increase knowledge and awareness of the population

• Establish a proper surveillance system

• Ensuring sustainability• Conduct national survey to

track progress

The Way Forward (2)

• It tells us “WHAT• It tells us “PROBLEM”

• But it does not tell us “HOW?• Left us with:

‘ISSUES , UNCERTAINTIES, and ‘HOPES’

Action Non Material Approach