Note: GAIN has reviewed a draft of this post and added responses below.

The Global Alliance for Improved Nutrition (GAIN) focuses on reducing malnutrition by fortifying foods and condiments with essential nutrients and through other interventions. We have been considering GAIN for a 2014 recommendation for its work on Universal Salt Iodization (USI) because of our impression that iodization has strong evidence of effectiveness, cost-effectiveness, and room for more funding (our take on salt iodization is in our post on ICCIDD), and our understanding that GAIN is one of only a few organizations working on salt iodization on a large scale in many different countries. We decided to prioritize GAIN after speaking with Greg S. Garrett from GAIN as part of our investigation of ICCIDD.

We’ve now spent a considerable amount of time talking to GAIN and analyzing documents GAIN shared with us. This post shares what we’ve learned so far and what questions we’re planning to focus on throughout the rest of our investigation. (For more detail, see our detailed interim review.)

Broadly, GAIN’s USI work includes advocacy, technical assistance, supplying equipment and building supply systems for potassium iodate and iodized salt, training government officials and salt producers, and monitoring coverage and impact, among other activities.

GAIN has completed the first phase of our investigation process and we view it as a contender for a future recommendation. We now plan to make a $100,000 grant to GAIN (as part of our “top charity participation grants,” funded by Good Ventures). However, we are planning to prioritize work on other organizations first because we think that will yield a higher return on our time. GAIN is a challenging organization for us to evaluate, because its work (e.g., training/monitoring) is often several steps removed from increases in the impact we hope to see (e.g., improvements in iodization rates); we have evaluated and recommended organizations like this before, but with the information we currently have from GAIN, we feel we are still far from a full understanding of GAIN’s work and impact.

Questions we hope to answer in our ongoing analysis

We feel that we are still at a relatively early stage of our investigation of GAIN and have many important, open questions.

What’s GAIN’s track record at improving USI programs?

There are two components of this question, and we have only limited information on both: (1) in the countries that GAIN has worked, is a higher percentage of salt being iodized at the correct concentration than it was previously, and/or have measures of iodine levels in the population improved? and (2) what evidence is there that GAIN caused any improvements that are observed?

On (1), the trend seems quite mixed: in a set of nine countries, use of adequately iodized salt decreased in three countries, increased by a small amount in four countries, and increased substantially in two countries. Were we to rely on this data, we would need more information on the data sources. The data is not necessarily comparable within or across countries due to different survey design and salt iodine assessment methodology.

GAIN’s response: We have advocated globally and ensured that within our target countries a sub-sample of salt will be tested for iodine using a recognized quantitative method in any assessment taking place. This is reflected in the fact that eight of the nine update assessments measured salt iodine quantitatively, and all forthcoming (2015) end of project assessments will include quantitative analysis for the entire salt sample. In the interim, the data we have access to (from surveys and other reliable sources of information since project start) for nine of our target countries show that baseline coverage of adequately iodized salt was 72.6%. This coverage has increased to 80.3% in these nine countries over the project period to date, representing an increase in the reach of adequately iodized salt to approximately 195 million people, mostly in China, Ethiopia, India and Pakistan.

We’ve looked more closely at iodization trends in four countries that GAIN highlighted to us in case studies of its work. In Bangladesh and India, rates of adequately iodized salt increased by a small amount (4 to 7 percentage points). In Ethiopia, GAIN reports that iodization rates have roughly doubled (from 20 to 40%) over a period that included GAIN’s involvement in the country (but follow up data is incomplete). In the fourth country, the Philippines, GAIN has only provided data for a group of salt producers it worked with, and found that samples meeting iodization standards increased from less than a third to over 80%.

We put limited weight on these claims – particularly in the last two examples – because we have not seen details of how the data was collected.

GAIN’s response: In India, which is self-sufficient in salt supply, the most recent data are based on supply QC reports from the national salt management information system, the development of which was a major achievement of GAIN support to the Salt Dept. This system has greatly facilitated obtaining timely and higher quality data, comparable over time, on iodized salt supply and quality. The system and rapid review time also increases accountability of salt producers as well as regulatory monitoring staff. How the supply QC data relate to household access to iodized salt will be determined after the national survey which will be conducted before the end of 2014. 2013 data for Ethiopia were presented at the Micronutrient Forum by the Ethiopian Public Health Institute. These salt iodine data are from a sample of over 5,000 households, selected from 354 enumeration areas to provide regionally and nationally representative data. The full national micronutrient survey, conducted by the end of 2014, will repeat the collection of salt samples and also include assessment of iodine status. It is expected that this will have improved considerably, in line with increased access to iodized salt, since the very low baseline. GAIN has been a key player working with the salt producers in challenging conditions to establish a sustainable KIO 3 supply, develop iodization technology and is currently working on these as well as on improving quality control and regulatory monitoring of the salt supply with FMHACA.

For (2), linking GAIN to improvements in specific countries will be difficult because its activities (such as technical assistance, monitoring, training, etc.) tend to be a few steps removed from the outcomes of improved salt iodization and iodine consumption rates. Furthermore, GAIN generally works in collaboration with other groups (more below), making attribution to one party difficult or impossible. For more details on GAIN’s activities and reported accomplishments in these countries, see our interim review.

GAIN’s response: GAIN focuses its work primarily on proven drivers of supply which are mapped against the 2011 WHO/CDC logic model for micronutrient interventions in public health. GAIN works closely with partners (government, private sector and other agencies in particular UNICEF) and therefore attributing progress to one agency alone and set of activities can be challenging.

Do we have a comprehensive understanding of GAIN’s USI activities?

We have found it challenging to understand what, specifically, GAIN’s work on USI involves. This is because GAIN’s activities on USI vary considerably across countries and it works in 16 countries, and GAIN works closely with UNICEF, ICCIDD, and governments on this work, making it difficult to understand GAIN’s role. To date we have focused on understanding GAIN’s work in 4 countries because (a) GAIN has shared the most information for these countries, and (b) together they account for roughly 50% of its primary grant for USI.

Details in our interim review of GAIN.

GAIN’s response: As explained above, GAIN focuses its work primarily on proven drivers of supply which are mapped against the 2011 WHO/CDC logic model for micronutrient interventions in public health. GAIN works closely with partners (government, private sector and other agencies in particular UNICEF) and therefore attributing progress to one agency alone and set of activities can be challenging. Specifically, in addition to ongoing policy and advocacy and monitoring of national programs (e.g. designing and delivering coverage surveys) GAIN’s work can be summarized by the following four proven supply drivers: 1) improving quality assurance quality control/regulatory monitoring/improving testing capability; 2) integrating the use of adequately iodized salt in the food industry; 3) designing models for sustained KIO3 procurement; and 4) delivering innovations along the supply chain which apply positive pressure on iodized salt supply.

Room for more funding

GAIN’s USI work is mostly supported by a large, multi-year grant from the Gates Foundation that is ending in 2015. It is not yet clear if the Gates Foundation will renew this support. It seems likely that if it does not, GAIN will have a funding gap for its USI work. We have not yet discussed with GAIN how it would prioritize USI work at different levels of funding.