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Kraisid Tontisirin, George A. Attig, and Pattanee Winichagoon
In the context of the eight major themes proclaimed at the Rome meeting of the International Conference on Nutrition in 1992, an eight-stage process incorporated thematic components into the development agendas of developing nations. The eight progressive stages, which are presented here in the context of Thailand's experiences, are recognition that nutrition is a national (or community) problem, a systematic national (community) nutrition assessment, building a critical mass around prime movers, gaining political and social commitment, taking concrete steps toward creating intersectoral collaboration and planning, expanding awareness and initiating action, integrating nutrition into social and health development efforts, and designing programmes that improve people's quality of life by involving community members as agents of change, not simply passive receivers of government services.
At the 1992 International Conference on Nutrition (ICN), held in Rome, eight major themes for nutrition strategies were identified, namely: improving household food security; protecting consumers through improved food quality and safety; caring for the socio-economically deprived and nutritionally vulnerable; preventing and managing infectious diseases; promoting appropriate diets and healthy life styles; preventing specific micronutrient deficiencies; assessing, analysing, and monitoring nutrition situations; and incorporating nutrition objectives into development policies and programmes. These themes represent priority target areas on which nations can focus their development resources for improving their populations' hearth and nutrition status.
One of the chief concerns underlying most of the themes and their strategies is that of motivating countries to take action by incorporating nutrition objectives into development policies and programmes. It is rightly believed that this rests firstly on governments' recognizing that nutrition and socioeconomic development go hand in hand. Many international conferences and agencies have directed their resources toward awakening developing countries to this realization. Many have also sought the signatures of government representatives on various global agreements to improve the health and/or nutrition situation of vulnerable groups.
Yet, although this motivational approach may be necessary for some of the world's developing countries, for governments in Asia, or at least within the South-East Asian and Indochinese regions, national-level decision makers for the most part already realize the importance of health and nutrition for achieving national development objectives. This is evidenced most clearly by the increasing requests they are making to international development agencies for assistance in establishing national nutrition policy committees and programmes as well as in improving their infrastructures so that services can be delivered more adequately. What is lacking, therefore, is not really commitment or a list of concrete (although sometimes ideal) strategies, but a process that developing nations can turn to for guidance in incorporating components of the eight themes into their development agendas. In looking for this process, several developing countries in Indochina especially are turning to their neighbours who have succeeded in bringing their health and nutrition problems under control. One country that is under intense scrutiny is Thailand, particularly in light of its remarkable ability to integrate food and nutrition considerations into national development policies, objectives, and programmes .
Thailand thus can be taken as a case study in demonstrating an eight-stage process by which developing nations can begin to merge their nutrition considerations and strategies encompassed under the eight ICN themes into development policies and programmes. The eight progressive stages are (I ) recognition that nutrition is a national (or community) problem, (2) a systematic national (community) nutrition assessment, (3) building a critical mass around prime movers, (4) gaining political and social commitment, (5) taking concrete steps toward creating intersectoral collaboration and planning, (6) expanding awareness and initiating action, (7) integrating nutrition into social and health development efforts, and (8) designing programmes that improve people's quality of life by involving community members as agents of change, not simply passive receivers of government services.
The eight stages
Recognizing nutrition problems
Improvement in a nation's or community's food security and nutrition situation does not happen overnight. In Thailand, for example, it spanned several decades, with actual nutrition policies, plans, and programmes being more recent innovations . The first essential element is recognizing that nutrition is a national problem. Gaining this recognition is a long process; as discussed below, it rests on consolidating a critical mass of prime movers who have the realistic ability to influence government decision makers. Change, in this case, must come from inside, since outside pressure often fails to attain its objectives fully.
In Thailand, a reference in the first National Economic Development Plan (NEDP) (19611966) revealed increased concern that nutrition was a public health problem. It noted that, although Thailand has surplus food and no one dies of starvation, measures are needed to cope with the malnutrition that occurs in quite a number of cases among the rural population as a result of ignorance and lack of a balanced diet.
As in many countries at this early stage, however, the attention given to nutrition in Thailand's first NEDP was not followed with a more in-depth reference in the second plan (1967-1971), which covered only one nutrition project, the Applied (Expanded) Nutrition Project, initiated in March 1961. Nonetheless, this project's operational strategy was an antecedent to and a springboard for ministerial inter-sectoral collaboration in developing national food and nutrition policies. It was also Thailand's first attempt to implement a programme to improve nutrition. The project was conducted by several cooperating ministries in ten villages in the northeastern province of Ubon, with support from UNICEF, WHO, and FAO. It focused on controlling nutritional deficiency diseases, providing nutrition education, and producing and promoting protective foods. Community participation was secured through schools, which provided screening for malnourished children, vitamin A supplementation, and combined nutrition and health education.
Although in Thailand the Applied Nutrition Project was a good programmatic start, greater government commitment is often required for initiating nutrition polices and programmes. This requires ammunition in the form of a comprehensive national nutrition-status assessment to supply information for central-level advocacy, make decisions about priority problems, identify target groups, and select possible actions. More important, however, this information serves as a basis for intersectoral dialogues that are indispensable for encouraging realistic and complementary actions to improve nutrition, recognizing the benefits and trade-offs of short-term and long-term priorities within the various sectors.
In Thailand, this assessment began in 1960, when a joint Thai-United States team conducted a carefully planned national nutrition survey. The results, published by the Interdepartmental Committee on Nutrition for National Defense (ICNND) , showed that average dietary intake was about 100 calories below the estimated average daily requirement of 1,871 calories (using adult equivalence to estimate individual intakes from household-level surveys). Protein-energy malnutrition was the most severe problem, especially among pregnant and lactating women, infants, and preschool children in poor urban and rural areas. Anaemia was highly prevalent in rural households, especially among pregnant and lactating women. Vitamin A, thiamin (vitamin B1), and riboflavin (vitamin B2) deficiencies, iodine-deficiency goitre, and urinary bladder stone disease were found in northern and northeastern regions. Of similar importance were recommendations made in the ICNND and other reports calling for an integrative effort on the part of different government sectors in solving the problems identified by the survey.
Building a critical mass around prime movers
Information about a nation's nutrition situation is not enough to promote action. Building a critical mass of people-experts and public alike-concerned with addressing the problem is the next indispensable element. Growing numbers of publications such as the ICNND report showed that, whereas there might not have been a national awareness of Thailand's nutrition problems, awareness of such problems was definitely increasing among concerned researchers and public health workers. Furthermore, several Thai scholars received training in the United States and Europe during the 1950s and 1960s and returned home with concern about the country's direction and wellbeing. These scholars also participated in various community-based nutrition programmes, thus gaining valuable experience of community life and the requirements for implementing acceptable community activities. In addition, they were aware of the disparities between the nation's fast economic growth and the large percentage of the population living in poverty.
Consequently, these persons formed a critical mass and served as prime movers who could make use of information from several surveys on the magnitude and severity of national nutrition problems and advocate feasible interventions based on firsthand experience. This experience, together with survey data, indicated that malnutrition was an outcome of several factors closely linked to the country's development. Solutions, therefore, had to be holistic and go beyond a single sector's responsibility. Operational research for implementing direct interventions such as the Applied Nutrition Project provided options for policies, plans, and problem-solving programmes that would be valuable for policy makers and programme implementers. Finally, inputs from international agencies came in various forms of support: money, experts, and new or advanced knowledge.
Political and social commitment
In Thailand, these elements led to heightened political and social commitment at national and even community levels, which in turn led to policy and programme decisions to control and prevent nutritional problems such as protein-energy and micronutrient malnutrition. This commitment, moreover, came in response to a spectrum of awareness from political concerns about the attainment of national development objectives, on down to public opinion. Thus, pushing forward nutrition strategies requires communicating not only with high level officials but with the general public. Messages and advocacy statements for each target group, moreover, have to address existing needs, whether increasing the nation's gross national product or improving household food security or a child's health status. Political stability, favourable economic growth, and societal coherence are also positive requirements for developing solutions to prominent nutrition problems.
In this respect, the 1970s were years of increasing social consciousness in virtually all strata of Thai society, and the momentum for change, already in place, gained force throughout the decade. In response to popular demand, Thailand experienced a brief period of democratic and constitutional rule from October 1973 to October 1976, accompanied by increasing concern for the plight of the poor and for the widening gap in income distribution. This concern was perhaps best exemplified by the words of Prime Minister Sanya, who held office from October 1973 until early 1975: "I never thought the hardship of the people would be so much.... It is the duty of everyone to help the people have a better life" . Thus, Thais realized that, despite the growing national prosperity, many people's basic human needs were unmet.
Also during the decade, Thai scientists expressed growing concern about nutrition issues and published several reports documenting the country's prevalent nutritional deficiencies. This growing awareness was not restricted to academics alone but was made known to the general public as well as to government planners, policy makers, and politicians. The vicious cycle of malnutrition, disease, and poverty was publicized by nutrition scientists, the Nutrition Association of Thailand, and other voluntary groups. The consensus among the prime movers was that advocacy efforts should focus on making policy makers understand that improving the people's nutrition status is an investment, not an expense, and is fundamental to future development, and that malnutrition is not a health problem but an outcome of social disparity and must be addressed beyond the health sector. To create further movements it was crucial for these thoughts to be communicated effectively to policy makers to gain their support. Active involvement of several ministries in efforts to alleviate nutrition problems was also necessary.
Intersectoral collaboration and planning
With support from international agencies and the cooperation of the Ministry of Public Health, an inter-ministerial workshop was held in 1973 to turn intersectoral collaboration from an ideal concept into a concrete reality by delegating realistic roles and responsibilities to each government sector. Once again, efforts had to focus on placing responsibilities within the hands of those who could best undertake them rather than simply passing the buck to another sector. This is especially important for nutrition strategies, since virtually all of them require multi-sectoral efforts if they are to be implemented effectively and efficiently.
Working groups thus identified major problems in implementing nutrition programmes within each sector, prepared guidelines for proposed programmes, and discussed ways to coordinate these efforts. The objectives of this early intersectoral effort were to review basic information on existing or proposed programmes within the third National Economic and Social Development Plan (NESDP) (1972-1976) and prepare guidelines for developing a national nutrition policy for submission to the National Economic and Social Development Board. In short, the economic sector evaluated the relationship between nutritional deficiencies and economic development; the agricultural sector examined ways to improve nutrition through crop production and animal husbandry; the public health sector looked at linkages among nutrition status, food consumption, demographic factors, and health; the education sector scrutinized nutrition training and education of the population from primary to graduate school, including public education; the social development sector evaluated the nutrition status of various socio-economic groups and possible strategies for improving it; and the research and training sector developed a training curriculum for nutrition personnel at all levels and conducted research, especially applied and operational research, in response to identified problems.
These deliberations produced several important conclusions. Because malnutrition has many causes, it can be controlled only by coordinating health-sector activities with those of all other involved sectors and agencies. Furthermore, a national authority must plan and coordinate food and nutrition policy in line with development policy. In fact, this conclusion recognized for the first time that nutrition issues require central planning if they are to become a solid part of a nation's interests and programmes. The National Economic and Social Development Board was chosen as the organizing body since it was best suited to oversee national nutrition planning and was already experienced in multisectoral coordination. In addition, the board was in the process of developing the fourth NESDP (19771981) and therefore could take action in a timely manner.
This is the stage most countries within the Indochina region especially, such as the Lao People's Democratic Republic, are currently at, as they start to establish national-level food and nutrition policy and planning committees. The challenge before them is to develop and implement these activities on a nationwide scale .
Expanding awareness and initiating action
Once a central food and nutrition planning committee is set up, the next element rests on establishing specific plans as part of larger national development plans. Historically, Thailand's nutrition programmes have been components of national health development plans that were implemented in conjunction with the five-year National Economic and Social Development Plans. In 1977 the first National Food and Nutrition Plan (NFNP) was included as a part of the fourth NESDP. The first NFNP listed seven major nutrition problems: protein-energy malnutrition, iron-deficiency anaemia, vitamin A deficiency, beriberi from thiamine deficiency, goitre caused by iodine deficiency, angular stomatitis induced by riboflavin deficiency, and urinary bladder stone disease resulting from phosphorus deficiency. Protein-energy malnutrition was considered the most significant and a priority because of its high prevalence, especially among pregnant and lactating women and preschool and school-age children. Among the possible causes identified were inadequate food production for household consumption, an inefficient and inequitable food market system, poverty and high population growth, improper food habits and lack of nutrition education, and inadequate health services.
The first NFNP set out ambitious and comprehensive goals to improve the nutrition status of the population by tackling it on many fronts, most notably the improvement of health care and hygiene, increased food availability, establishment of 1,200 child-nutrition centres to combat malnutrition through the direct feeding of centrally processed supplementary foods, nutrition education, and the improvement of socio-economic conditions of the vulnerable groups. The plan targeted rural infants, preschool children (under five years old), pregnant and lactating women, and, to a lesser extent, school-age children. In reality, the programme was not fully implemented because of a lack of full inter- and intrasectoral coordination. Furthermore, although some action plans were well defined, planning was done entirely from the top down. It was not surprising then that the first NFNP produced disappointing results, and 50% of preschool children continued to suffer from protein-energy malnutrition. However, the plan's most significant accomplishment was the creation of a strong awareness of nutrition problems among public and private sectors alike and at all levels. This led to stronger political commitment on the part of the nation's policy makers.
Integrating nutrition into social and health development
By the end of the first NFNP, policy makers, economists, and nutritionists were coming together even more to view malnutrition as a multifaceted problem of social, economic, and human-capital dimensions. Improvements could no longer he made simply through short-term curative measures. Rather, nutrition had to be integrated into the nation's broader social and health development efforts (the alleviation of poverty, primary health care) if long-term results in nutrition improvement and socioeconomic development were to be achieved.
Furthermore, up to this stage, the interventions were largely top-down and curative. The emphasis was on getting the government system going and securing the necessary infrastructure and personnel prerequisites. Little attention was given to developing a bottom-up, participatory strategy, but this began to change by the time of the second NFNP (under the fifth NESDP) and came into full force under the third NFNP (sixth NESDP).
The main thrust of the fifth NESDP, which contained the second NFNP, was to embed nutrition policy within broader national social development policy. The latter centered on a Poverty Alleviation Plan (PAP) entailing the development of backward areas, along with a primary health care approach to health development. This emphasis marked an important turning point in Thailand's approach, formally focusing attention on overall economic growth and its trickle-down effects for rural development. The success in implementing community-based nutrition programmes was further strengthened and accelerated by the long-term policy to achieve health for all by the year 2000. Both the PAP and primary health care policies placed nutrition as an important component for reaching the goal.
The Poverty Alleviation Plan
One of the important milestones of the PAP was that, instead of setting unrealistic nationwide goals, it defined rural poverty areas requiring urgent attention. Using existing population data, the plan targeted high-poverty rural areas as the focus of an intensive effort to meet basic human needs and to introduce simple agricultural technologies. Thus, it provided major areas for all implementation agencies in their efforts to integrate and coordinate rural development activities at both central and rural levels. The plan received very strong political support throughout the 1980s under the following principles:
» Primary consideration was taken for the development of
specific areas, with high poverty concentration to be given top
» The population's living standard was to be developed to a subsistence level, with minimum basic services to be available everywhere in high-poverty rural areas.
» Emphasis was laid on the need to make improvements so that the people could gradually do more to take care of themselves.
» Low-cost technology would be introduced that would be handled by the people themselves.
» Maximum participation by the people in solving their own problems would be encouraged.
Under the PAP, four key programmes and all associated activities were directed toward 288 target districts in 38 provinces identified as priority areas. The major ministries-Health, Agriculture, Education, and Interior-integrated their activities through committees at each level. Activities were integrated and targeted at poor villages through village committees. The four key programmes that were implemented were as follows 
» Rural job-creation programme. Jobs were created for rural
people during the dry season to boost their income. Most
employment was given to people in their own locale so that they
would remain in their communities and participate in
» Village development projects and activities. The activities included village fish ponds, water sources, prevention of epidemic diseases affecting poultry, cattle, and buffalo banks, and others, all focused on the rural poor to improve their economic status and household food security.
» Provision of basic services. Public services for the rural poor such as health facilities and health services, nutrition, clean water supplies, and literacy education programmes were directed to the target areas.
» Agricultural production programmes. Important programmes included nutritious food production (especially crops used for the supplementary feeding of young children), upland rice-improvement projects, and soil-improvement projects. Income generation and household food security were the direct benefits.
Facilitating this process was the fact that the nation's rural development approach also encompassed an organizational change. Rather than having numerous sector-specific committees that hindered intra- and intersectoral coordination, a single national committee was established and placed in charge of development policies and infrastructure considerations from the central level on down to the village. This was a striking organizational reform that combined macro- and micro-level structures to support both the top-down macro-policy and bottom-up planning by the community and peripheral government resources.
In the following sixth NESDP, the PAP approach continued its concentration on self-reliance and adjustment to the changing economic conditions and environment. In this plan, the PAP's target-specific approach was expanded, and villages were classified into three categories:
» Backward or poor areas, where people faced four or five
problems in basic needs for their livelihoods, such as poor
transportation facilities, no landholding for agriculture, low
agricultural productivity, and poor health and environmental
sanitation. Slightly more than 5,700 villages were in this
category and required intensive government support as in the
earlier PAP areas.
» Intermediate areas, facing only one or two of the problems identified in the poor areas. Approximately 35,500 villages were included, and they were given some government inputs to allow them to identify their problems and take action to rectify them.
» Advanced areas with very few problems and economically better off. Over 11,000 villages fell in this category. Since they did not necessarily need government inputs, they were encouraged to work with the private sector.
The results of the PAP from a food and nutrition point of view were quite promising . Rural household food security improved because of the availability of more nutritious foods such as fish, poultry, vegetables, and fruits. More than 60,000 families used new agricultural technologies, and there were 2,655 new village fish ponds at the end of the fifth NESDP. In addition, health services through primary health care reached more than 80% of the targeted villages. Thus, the PAP contributed a certain amount to the reduction of the prevalence of protein-energy malnutrition during the period (discussed further below).
Primary health care
Like the PAP, the concept of primary health care emphasized community self-reliance, requiring the facilitation of personnel development, management, and community financing . The core principle was that community members should become more involved in realizing and solving their own health problems. This movement toward a more community-sensitive approach, moreover, was not restricted to the health sector. It was intersectoral and operated by the four key ministries .
This bottom-up approach was also supported by earlier successful efforts to help rural people become more involved in their own health development. Although the Alma Ata Declaration was formally adopted in 1978, with Thailand as one of its signatories, Thailand had already conducted several large pilot projects aimed at improving health services. Several projects, such as those in Sarapee and Lampang, contributed strategies and prototypes for primary health care activities that placed concern for health and nutrition more firmly within the local health care system .
One of the country's main strategies for doing this arose out of the realization that rural people's acceptance of local health services depended on their own active community participation and understanding of the types of services available. To increase community participation, a new approach was developed, focusing on selecting villagers to be trained in the treatment of simple endemic diseases, the importance of immunization, environmental sanitation (emphasizing latrines and drinking water), parasite control, malaria (blood tests, basic treatment and control measures), and family planning. These community trainees were divided into two groups. The first group, known as village health volunteers, were trained to undertake all of these services, including the treatment of minor illnesses, and the second group, called village health communicators, were responsible for disseminating health information, particularly in terms of health education and the transmission of information in case of communicable diseases or epidemics. The members of both groups were all volunteers who participated in integrated health development activities with support from government health offices. As a result of this scheme, local people's acceptance of health services increased considerably . This model concept was then tested in other areas with great success, and it now forms the major frontline of Thailand's primary health care system.
By 1989 over 500,000 village health communicators and 50,000 village health volunteers had been trained, covering almost all the villages in the country. A growth-monitoring programme was carried out by health personnel and these volunteers in the villages. Simple and practical indicators and nutrition education for all age groups were introduced. The volunteers and communicators were responsible for weighing, interpreting the results, and communicating them to mothers. Moderately and severely malnourished children received more attention, and their mothers were encouraged to participate in the activities.
Thus, the second NFNP integrated nutrition into the primary health care plan, focusing on areas targeted by the rural development-oriented PAP. Specific activities included conducting nationwide growth monitoring, promoting village-based production and consumption of supplementary foods in poverty-stricken districts, providing supplementary food to severely malnourished preschool children, subsidizing school lunches in rural primary schools, advancing nutrition education by public campaigns and home visits, and fostering nutrition-related research, training, and extension activities.
By the end of the fifth NESDP and the second NFNP (1982-1986), the nutrition status of infants and preschool children had dramatically improved. Severe protein-energy malnutrition was practically eliminated, and only a very small percentage of moderate malnutrition remained. Weighing by a simple beam balance and the use of growth charts by mothers and village health volunteers were shown to be feasible and useful for identifying problems. Simple technology for village-level supplementary food processing was promoted to overcome the disruptive distribution of centrally produced supplementary food.
Village self-financing schemes were also tried with some success. For nutrition, villagers formed cooperatives to produce supplementary food for undernourished children in their communities. Surplus food could be sold to other communities that could not produce such items, and the income would then be put in a village nutrition fund that would support the food-supplementation programme as a continuing process . Other such funding schemes were also initiated, such as village drug funds, the profits of which would be put into a revolving fund for village-development activities.
Improving the quality of life by community participation
The next step is to expand the concept of having good health to having a better quality of life. This places greater emphasis on nutrition as a social and community development goal rather than simply as a health concern. This is very important at the community level, since health and nutrition are often not a high priority, and they must be integrated into more holistic community development needs and programmes in order to be successful.
For Thailand, the third NFNP (1987-1991) continued to use the primary health care approach with multisectoral collaboration for planning and implementation. The quality-of-life concept, moreover, was translated into action using the basic-minimum-needs approach, and was implemented as a pilot trial under the PAP scheme in 1983. This approach provided a common tool for government officials and community members to identify problems, monitor progress, and evaluate accomplishments toward good quality of life. Simple and practical indicators, understood and measurable by the villagers, were developed on the basis of eight main categories of basic-minimum-needs indicators, including key food and nutrition considerations .
The important feature of this plan was the ability of the basic-minimum-needs approach to improve community participation and the integration of sectoral development activities. Similar strategies for nutrition continued in the sixth NESDP, and the approach was implemented nationwide to strengthen the integration of sectoral efforts. At present, over 95% of all the villages throughout the country are using basic-minimum-needs indicators to gauge their development status and achievements . Birth weight and weight for age of children under five years old and school-age children were the indicators defined for measuring adequate nutrition. Thus, nutrition activities became a means to achieve the goal of quality of life. Through this iterative process, it was expected that the understanding and confidence of the villagers would grow, promoting their increased participation. In these processes, local officers were expected to alter their role from that of active agents of change to that of facilitators or advisers. As a result, the most recent nutrition surveillance report (1991) showed that by the end of the sixth NESDP the prevalence of severe malnutrition was almost nil, and moderate malnutrition was reduced sharply.
One of the main reasons Thailand has been able to generate a relatively high level of community participation is that the programmes, especially those since the introduction of the basic-minimum-needs approach, combine top-down and bottom-up planning and implementation. The focus is on identifying, implementing, and evaluating programmes that fit with community members' needs, existing circumstances, and constraints. In short, nutrition initiatives are effective because they have built a team approach between local government officials and community members, and programme implementation relies heavily on people's participation at every stage, not solely government inputs. Such programmes came to be even more effective when they were adapted to accommodate existing environmental limitations and exploit social patterns and cultural beliefs instead of conflicting with them [7-9].
When the Applied Nutrition Project was implemented in the mid-1960s, nutrition was seen as a food problem, specifically a problem of lacking protein foods. During the first and second NFNPs, efforts were directed primarily toward improving the nutrition status of children under the age of five. Protein-energy malnutrition was the predominant concern, and strategies involved global approaches to improving its proximal (protein and energy deficiencies) and underlying (social and economic problems) causes. Activities included nutrition surveillance and growth monitoring, promotion of infant feeding, and village-based production of supplementary foods. Programmes for pregnant and lactating women were secondary in importance and consisted largely of nutrition education. Schoolchildren also received some attention, primarily through the school lunch programme.
The Applied Nutrition Project and the three NFNPs shared a common conceptual framework in attempting to involve ministries other than the Ministry of Public Health at the field operational level. Translating the multisectoral concept into action was not well conceived. Nevertheless, the salient feature of the first NFNP (1977-1981) was the acceptance among high-level planners, especially in the health sector, of the need for a broad perspective to alleviate nutrition problems. This realization was communicated to national policy makers and planners in several sectors. It was agreed that improved nutrition was an investment in national development. In addition, it was during this period that public awareness and concerns about malnutrition and its effects increased rapidly. Several mass campaigns, organized or promoted by the National Food and Nutrition Committee, played a large part in these developments.
During the period of the second NFNP, the rural development policy provided an umbrella through the PAP for nutrition to be one element or means to attain the broader end of national development. Another outstanding feature of nutrition programmes in rural Thailand was their community-based approach, which evolved from the concept of primary health care. The improved nutrition status of children under the age of five then became quite obvious during the second NFNP as a result of more community-focused efforts, and this trend continued to the end of the third NFNP. Although to a large extent nutrition activities may have been stopgaps during the first and second NFNPs, during the third NFNP concern for nutrition as a crucial element in long-term rural development for improved quality of life gained momentum. The sustainability and long-term impact of these approaches proved very promising. Adoption of the basic-minimum-needs approach during the third NFNP helped to strengthen bottom-up planning and the integration of efforts among various sectors at the community level. Restructuring the rural development scheme and policy at the macro level facilitated implementation at the community level.
As a result of these progressive efforts in alleviating malnutrition, the prevalence of malnutrition among children under the age of five declined markedly. Since the national nutrition programme was not implemented as a single intervention but was an integral part of consecutive socio-economic, health, and nutrition plans, it is not easy to sort out how much of the improvement is attributable to which elements of what policies or programmes; therefore, the cost-effectiveness of the nutrition components cannot be assessed. Moreover, it is quite evident that a community-based approach is a continuing process. All the components of the activities might in fact have played synergistic roles in nutrition improvement.
Most, if not all, of the above stages not only relate to macro-level nutrition development but are also key parts of micro-level processes. In short, although these stages are common to governments and communities as they seek to improve their nutrition situations, usually the process begins at the macro level as governments orient themselves and build the necessary infrastructure for nutrition, health, and rural development. Thereafter, the community process begins through the assistance of government, non-government, and international inputs. For Thailand especially, these elements merged into a threefold development strategy of political commitment (through national poverty alleviation, health development, and food and nutrition plans), health personnel development (from universities and the central level on down to community members), and intersectoral collaboration with emphasis on securing people's basic minimum needs. For other countries the actual strategy may be different, but the process and its required elements will most likely be common to all.
In this process, the eight ICN themes can be looked at in either of two ways. They can be seen as individual challenges that each country must assume in striving to improve the quality of life of its people. Each of these challenges has a multiplicity of solutions, some of which are practical and others ideal, depending on a country's resources and limitations. Alternatively, the themes can be seen collectively as interwoven determinants and consequences of a country's nutrition picture. Priority must be placed on identifying where particular themes overlap in terms of operational programmes and giving priority to those that can be tackled most effectively, given existing resources.
But the key to achieving the goals and objectives set forth by the ICN and inherent in these themes is embedding them within the national development process. This integration can be done in one of two ways. In the short term, stopgap programmes for each theme can be implemented to improve household food security, prevent infectious diseases and micronutrient disorders, and improve the situations of vulnerable groups. Examples of this from Thailand are the Applied Nutrition Project and several pilot community-based activities during the first NFNP. For the long term, though, the themes must become a part of an overall process of progressively integrating nutrition considerations into national development strategies (e.g., the Poverty Alleviation Plan and Thailand's quality-of-life movement) using the essential elements described here as a guideline. Perhaps now more than ever is the time to begin investigating and advocating potential sustainable processes for integration, rather than focusing on individual themes and strategies that might work in the short term but may have a very limited life in the long run.
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