Social Marketing Helps Eliminate Iodine Deficiency in Pakistan

PSI, UNICEF and the Government of Pakistan are successfully using social marketing in Pakistan to attack the problem of iodine deficiency which causes tragic health problems such as goitre, cretinism, stillbirths and deaf mutism. As a result of this innovative program, tens of millions of Pakistanis now consume iodized salt and are thus no longer at risk of iodine deficiency.

Iodine is a natural element required by the human body for proper physical and mental development. While most people receive enough iodine from their daily diets, more than one billion people worldwide are at risk of iodine deficiency disorders (IDD) because their soil lacks iodine and because they lack other access to foods rich in iodine.

Pakistan has been one of the most severely affected countries, with over 70% of the population estimated to be at risk of IDD in 1993. This level of iodine deficiency imposes tremendous developmental costs on the country because even mild cases, with no physical symptoms, can result in a loss of up to 15 IQ points. The IDD problem persists worldwide even though it can be easily avoided, through consumption of salt fortified with iodine. Even in countries where such fortification programs exist, a large percent of the population often is not reached.

To help solve this problem, UNICEF designed a new social marketing program with technical assistance from PSI. UNICEF implemented the program in the highly endemic northern regions of Pakistan with continuing technical assistance from PSI. Based on the success of this intervention, UNICEF subsequently expanded the project by contracting PSI's local NGO partner, Social Marketing Pakistan (SMP), to implement the project on a national scale. In consultation with the Government of Pakistan and with continuing support and funding from UNICEF and the Canadian International Development Agency (CIDA), the Pakistan Iodized Salt Project works with the salt industry to ensure a sustainable supply of iodized salt while simultaneously creating demand among consumers.

The Iodized Salt Project has produced impressive results in a short period of time. The percentage of all edible salt being iodized jumped from less than 2% before the project began in early 1994 to 19% by August 1995. Current estimates are that 30% of all edible salt is being iodized. The project has thus created over 35 million new users of iodized salt in less than two years. Millions of babies who would have suffered from IDD now have the opportunity to lead healthy lives. At project start, only three salt processors in Pakistan were iodizing their salt. Less than two years later, that number has risen to more than 450. Each of these processors has invested approximately $300 of his own money to purchase the necessary equipment for iodization.

There are close to 600 primarily small-scale, private sector salt processors in Pakistan who crush and grind rock salt using manual labor and technology that has changed little for centuries. The project provides them with the technical skills and motivates them to iodize their salt. SMP field staff visit each processor and provide a range of assistance which includes educating them on the benefits of iodization, assistance in procuring mixers at a reasonable cost, regular supplies of potassium iodate, assistance in developing packaging that incorporates the iodized salt logo with individual brand names, and training in marketing.

As the supply of iodized salt hits the market, the demand creation campaign ensures that consumers choose iodized salt instead of non-iodized salt. Central to the marketing campaign was the development of the "Hand & Pot" logo, which has become the universal symbol for iodized salt in Pakistan.

The demand creation campaign makes intensive use of mass media such as television and radio. The campaign has made the "Hand & Pot" logo a positive image, emphasizing the healthy family, rather than the negative aspects of IDD. In addition to mass media, a range of other communications channels are used to reach a variety of target audiences:

• In many rural and low-income settings, salt retailers are key motivators for consumers with limited access to media. Retailers are, therefore, courted and educated through giveaway campaigns that award prizes-such as posters, mobiles and other eye-catching point-of-purchase materials-for correct answers to IDD-related questions.

• Doctors, many of whom have outdated knowledge of the consequences and prevention of IDD, are educated during seminars, and are provided prescription pads with the iodized salt logo, reminders of IDD prevention to both doctors and their patients.

• Teachers are trained to educate elementary school children and their families about the benefits of iodized salt; children are given "fun" testing kits that they use to test their family's salt-if it turns purple, it's iodized.

• Volunteers from collaborating grassroots NGOs reach remote villages. The project trains these volunteers to integrate correct messages about the importance of using iodized salt with their other social and health communications campaigns.

This social marketing model has not only achieved dramatic results, but also has created dynamics that will lead to continuing efforts to eliminate IDD in Pakistan. The key lies in industry buying into the process. For the first time, small salt processors in Pakistan are spending their own funds to promote iodized salt. Whereas salt was previously a generic commodity, it has now become a brand-name product, with each processor promoting its own brand and the fact that the brand is iodized. Salt processors have begun an impressive array of their own promotional activities, including giveaways and prize schemes for consumers and distributors, mass media advertising, participation in fairs, sports events, and seminars. SMP/PSI staff provide marketing assistance which helps the salt processors make these promotional efforts professional and effective.

Key lessons learned from the Pakistan Iodized Salt program include:

• It is essential simultaneously to stimulate the demand for, and supply of, iodized salt. Campaigns in other countries which have sought only to raise awareness of IDD or only to increase the supply of iodized salt have rarely succeeded in reducing IDD significantly.

• Convincing private sector salt processors to invest their own funds makes the program effective and sustainable. A salt processor who has purchased mixing equipment, packaging and other items is far more likely to iodize his salt, to iodize correctly and consistently, and to continue to iodize, than a processor who has simply received equipment and materials free of charge via a government or donor subsidy. This concept is central to all of PSI's social marketing projects-namely, that a consumer who pays for a product is more likely to value the product and to use it than is someone who receives it free.

• Legislation requiring that all salt be iodized, while important, has been ineffective on its own in countries where enforcement is difficult. Rather, legislation should accompany programs, such as the Pakistan program, which work with the private sector.

• International donors and governments are often not structured to work directly with the private sector. Nonprofit social marketing organizations, like PSI and SMP, provide the critical bridge between public and private sector. PSI and SMP staff work directly with private sector actors, such as salt processors, providing them assistance in important areas, such as packaging and marketing.

The elimination of Iodine Deficiency Disorders by the year 2000 was one goal adopted by government leaders at the 1990 World Summit for Children, and fortification of salt with iodine is recognized as the most effective and cost efficient strategy to achieve that goal. Indeed, a recent evaluation by the World Bank found that micronutrient programs have the greatest cost/benefit ratio of all health interventions. PSI will soon apply the lessons learned in Pakistan to iodized salt social marketing projects in other countries facing this tragic, but preventable, problem.

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