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Community-based surveillance for action towards health and nutrition: Experience in Thailand

Aree Valyasevi. Pattanee Winichagoon. and Sakorn Dhanamitta

Nutrition surveillance has been in place in Thailand for more than ten years. Nutrition was first addressed as an explicit entity within the national development policy during the fourth National Economic and Social Development Plan (NESDP; 1977-1981). Surveillance was conceived as an important component of a nationwide nutrition programme, and an operational strategy to implement it was sought.

Early nutrition surveillance in Thailand

Protein-energy malnutrition was identified as the highest-priority nutrition problem among Thai children under five years old. When nutrition improvement was first made one of the country's goals in the NESDP, surveillance was included as an activity in the programme. It was intended to provide information for policy makers and planners. For reasons of practicality and simplicity, the nutrition-surveillance system first focused on collecting anthropometric data. However, it was not made very clear how the actual routine data would be collected. Moreover, at the time, the implementation of nutrition activities depended entirely on top-down decision; very little input came from people in the communities to address their problems.

During the late 1970s several studies were undertaken to improve the effectiveness of nutrition programmes. Other community interventions, such as village-based infant supplementary food processing and distribution, have been investigated to facilitate the implementation of primary health care (PHC). Particular emphasis was given to mobilizing indigenous resources and strengthening community personnel to participate in improving health and nutrition as well as other community development programmes.

A community-based nutrition programme

Integrating the nutrition of young children into primary health care

Since 1979 Thailand has adopted a primary health care strategy as the main thrust to improve the health of the population [1], with nutrition surveillance designed to be an integral part of the nutrition component in the strategy. An important element of the PHC strategy was to enlist personnel from within the communities. This resulted in a huge group of volunteer personnel in two categories: "village health communicators," who can dispense information such as appointment dates and simple health messages, and "village health volunteers," who provide leadership and can also perform simple care in addition to conducting nutrition and health education. Both types of volunteers are key agents in the community to promote primary health care.

The terms "nutrition surveillance" and "growth monitoring" (later, "growth monitoring and promotion") were introduced and used interchangeably. Prior to nationwide implementation, the feasibility of implementing nutrition surveillance was explored. A pilot study was conducted in 1978-1979 by the Ministry of Public Health (supported by USAID) to train village volunteers and mothers to weigh and interpret the nutrition status of children under the age of five. Simple weighing scales and "road-to-health" growth charts were used. Actual implementation of the programmes, however, did not start until the early 1980s.

Weight is used to classify children into various levels of nutrition status and to target actions accordingly (fig. 1). The child's weight-for-age is plotted on a growth chart and the severity of malnutrition [2] (and Gomez classification) is interpreted and recorded. Children with second- and third-degree malnutrition receive both food assistance and nutrition education, and those with mild malnutrition or who are of normal status are given nutrition education. Individual weights are recorded on both a growth chart and an individual form. The growth charts are either returned to the mothers or shown to them and kept by the volunteers. This very first step serves to identify problems.

Once the children are classified into one of the four categories (normal, first-, second-, or third-degree malnutrition), instructions are given for managing each status level. In emergencies, health personnel may refer seriously malnourished children to a hospital. All malnourished children, particularly those with second- and third-degree malnutrition, are monitored closely until improvement is observable. Additional investigations are performed if the improvement is less than expected. This system has been in place since 1982, during the fifth NESDP. Health personnel and PHC volunteers are the ones who cope with the immediate causes of the problem.

FIG. 1. Community-based surveillance for action to improve nutrition (N = normal; 1st, 2nd, 3rd = degrees of malnutrition)

Broadening the use of nutrition data In community-based efforts

During the first five years of promoting health and nutrition through PHC, progress was slow. Both community participation and the integration of resources from sectors other than health were much less than anticipated. An important obstacle was that people lacked information to make their own plans. Thus community people have to be trained to initiate and manage necessary services effectively themselves, and government personnel should serve only as facilitators. In addition, equity in providing at least the minimum needs of life is important. Therefore, a new approach evolved from these considerations.

The basic-minimum-needs (BMN) approach is defined as a socially oriented, community-based, intersectoral development process carried out by local people [3]. Its objectives are to attain a good quality of life for all people through meeting their basic needs, promoting an equitable allocation of resources, strengthening intersectoral collaboration among government personnel and partnerships between people and personnel, and ensuring community self-reliance.

Conceptually, the following list of basic needs was formulated, based on the premise that for a good quality of life the Thai people should have at least these basic elements fulfilled:

1. physical well-being of all family members, with emphasis on the health and nutrition of vulnerable groups (infants, children under five years old, school-age children, and pregnant women);
2. food availability (agriculture indicators);
3. shelter and security (housing and security);
4. education (primary education, literacy, access to non-formal information channels);
5. mental well-being (modest living, religion, avoidance of gambling, etc.);
6. a sense of belonging and cohesiveness (participating in community activities, cultural events, care of public properties, natural preservation, community leadership, etc.).

Thirty-two indicators wore eventually defined after field testing (table 1). These are useful for community programme planning to establish priorities for problems, set goals, formulate plans of action, and implement, monitor, and evaluate community efforts aimed at achieving a good quality of life. A goal is considered achieved if an indicator meets the criterion of success. Each village then can determine its needs and plan for further action.

To decide on action, villagers participate in village committees to define three categories of activities: those that can readily be handled by the villagers themselves (i.e., that are within their capabilities and available resources), those that require guidance or support from local personnel, and those that depend on inputs from external sources. Village committees, with the help of local officers, can develop a specific proposal to be submitted to a development committee at the subdistrict (tambol ) level or the like (fig. 2). Proposals are reviewed on a competitive basis, and new funds or required technical inputs are provided as appropriate. When all or same of the goals have been achieved, the community can decide if it would like to lift the cut-off levels of indicators or to include other relevant indicators.

TABLE 1. BMN indicators

a. The criterion of success set for each indicator can be modified (raised or lowered) as the indicator is achieved.

Good nutrition is one of the eight main components of BMN (table 1). For each component, simple indicators were identified for practical use. Three nutrition indicators were used: the nutrition status of children under five, that of schoolchildren, and low birthweight. In terms of the data and information actually used in nutrition surveillance at the community level, it is apparent that both quantitative and qualitative data are applied to identify problems, to perform causal analysis, and to identify possible actions to solve problems. Obviously, qualitative information is used unsystematically and is not well documented.

A major breakthrough of the BMN approach was the opportunity for community people to demonstrate their ability to identify and manage their own problems effectively. Moreover, it was made clear that villagers themselves are the change agents. They also monitor their own progress, negotiate funding, and so on. Mothers and volunteers in large numbers of communities learn to take responsibility for the nutritional well-being of their own children as well as others in their community.

FIG. 2. Community surveillance for action with the BMN approach

Coverage and Impact on children under five

Community-based nutrition surveillance has been in place for about a decade. The integration of the surveillance information and community-level action in the PHC and BMN approaches is believed to contribute significantly to improving the nutrition status of children under five. According to the surveillance report, the coverage of community-based nutrition surveillance is close to universal in rural Thailand. However, the actual coverage in terms of the number of children reached and followed regularly may have varied between 60% and 90%. It has been lower in industrial zones and in areas where migration is high. In addition, some populations are difficult to reach because of their geographical location (e.g., hill tribes) and cultural factors. Several small-scale studies have found that malnourished children were more likely to be dropped out or periodically lost from the system than healthy children. No safety net is available in the system to support these drop-outs.

Despite the system's imperfections, extensive efforts were made throughout the 1980s to expand community-based nutrition programmes. By the end of the decade, marked improvement in the nutrition status of children under five was clear (fig. 3). The prevalence of moderate to severe malnutrition (Thai standard and Gomez criteria) was reduced to only a small percentage.

FIG. 3. Malnutrition trends for children under five years old in Thailand-data for the first quarter of the fiscal year (Oct.-Dec.), 1982-1992 (Source: Nutrition Division, Ministry of Public Health)

FIG. 4. Flow of anthropometric data from community-based growth monitoring and promotion to the higher administrative infrastructure

Community-based nutrition surveillance data for policy-making

Four cycles of data collection and compilation have been carried out since 1983, and reports were available a few months after the data were collected.

After the data were collected and compiled by health personnel in the field, the weight-for-age indicator was aggregated at each administrative level for planning and budget allocation (fig. 4).

After each round of weighing, the data for individual children wore aggregated as village prevalences of malnutrition of the three levels of severity. The village aggregate data were then submitted to the tambol health personnel to be aggregated further by district and province. Once the provincial totals were calculated, they were sent to the central Nutrition Division of the Ministry of Public Health, which compiled regional and national aggregates of the prevalence, of malnutrition and coverage of weighing of children under five.

The same data base used for planing community action was also used for policy-making and programme planning at higher administrative levels. The nutrition variable (weight-forage) has been used by the Nutrition Division and planning agency, but only data from one round of growth monitoring has been used for higher-level planning. The variable is an integral part of the basic-minimum-needs/rural-development data base used by development committees at various levels. Most uses have been confined to descriptive data analysis. Nevertheless, several variables are considered simultaneously in the BMN package (to assess if any of the 32 indicators have met the criteria of success), although not necessarily their interrelationships. Thus the use is similar to that at the community level. However, at a higher administrative level, such as the province, other variables monitored by each sector in their routine reporting systems are included in making decisions.

Lessons learned

The community-based approach is essential for a successful development programme. Nutrition surveillance has been an integral part of PHC in Thailand. Volunteers and sometimes mothers have been trained to identify problems and to take action when malnutrition is identified. Thus nutrition surveillance information at the community level is closely linked with action. In reality, time and efforts by health personnel are necessary to prepare the community and to enable the people to learn and fit these activities into their daily lives. The accuracy of measurements and interpretation of growth charts, although important, are not the critical elements for proper action at the individual and community levels.

Integrating nutrition into the development context through the BMN approach is crucial, since malnutrition is not solely a health or agricultural problem. The BMN indicators help community members to identify factors that contribute to their problems in a holistic manner. Successful nutrition improvement was the result of cohesive strategies and innovative measures taken by the community.

It is feasible to decentralize decisions for action, but it seems that top-down inputs will inevitably be needed to facilitate community-level action. Simple indicators (reflecting basic needs for living) and unsophisticated data analysis (the prevalence of children below the cut-off point for each criterion) appropriate for the villagers and local personnel to absorb led to acceptance of the use of the data. The same variables can be used to assess the baseline situation, for monitoring purposes, and for evaluation by villagers. The accuracy of the data can be improved over time through repeated use. An added benefit of using only one set of variables is the simplicity and ease of communication among the parties involved. Moreover, in actual application, natural integration of qualitative and quantitative information occurred; however, this was not documented.

The use of weight-for-age as the sole indicator needs closer examination. Although it has been used under the BMN umbrella, the relationships among variables in the BMN package have not been adequately tested. It is not possible to know whether and how improvement in the nutrition status of children under five is actually attributable to the BMN approach, or how far it is the result of intensive inputs directed to these youngsters during the decade. Better understanding of the success in improving nutrition in Thailand will help in formulating future policies and plans in response to the rapidly changing environment and the transition of several health, demographic, and socio-economic indicators.

Nutrition and growth monitoring have been used for planning action at different administrative levels. Since it is only to be expected that coverage may be incomplete in each round of data collection, the prevalence estimates may have been biased. Moreover, the quality of data collection may have been less than adequate because of the use of a simple scale by relatively unskilled volunteers or mothers, age miscalculation, and other possible errors in the field. Therefore extrapolations from these data for planning at higher administrative levels require caution.

In conclusion, Thai experience shows the following:

» There is more than one loop of nutrition surveillance information action when a surveillance system is implemented in an administrative infrastructure. In the Thai context, a distinct information-action loop at the community level elicits community participation and action to solve problems by villagers. Personnel at the peripheral level work closely with the community and use very much the same set of indicators for their decisions. This micro-planning consists of identifying nutrition problems, causal analysis, and community action to solve the problems.

» A top-down approach in designing a nutrition programme did not result in any appreciable impact on the nutrition status of young children. However, a bottom-up approach alone is unlikely to yield better results, since some inputs from various technical sectors and external resources may also be necessary. A community-based nutrition surveillance and BMN approach, integrating both top-down and bottom-up inputs, was crucial in designing appropriate action for a community. It also elicited commitment by the community and responsible health personnel.

» The tools for nutrition surveillance for micro- and macro-planning are not necessarily the same: both the appropriate indicators and the level of sophistication of data analysis needed may be different. Simple tools such as the BMN indicators were practical and well accepted by the community. It is recognized that we have had no confirmation that the set of indicators adopted was optimal. Nevertheless, they are apparently adequate for creating awareness and motivating community people to achieve some concrete goals. Thus, they are valuable for micro-level planning, such as for forming a plan of action for community development.

For macro-policy, consideration should be given to the appropriate sampling procedures, validated indicators, accurate measurements of variables, and proper data analysis in collecting data. It is not necessary for new data to be collected every year. The periodicity of information should depend on how it will be used. It is not clear that the same set of indicators is appropriate for all administrative levels. A well-conceptualized framework for different types of decision-making is important and should take into account levels of administration and information users. Linking information to action requires much more attention than it has been given in the past.

References

1. Nondasuta A. Realization of primary health care in Thailand. Bangkok: Ministry of Public Health, 1988.

2. Subcommittee on Food and Nutrition Planning. National food and nutrition policy. Bangkok: Royal Government of Thailand, Office of the National Economic and Social Development Board, 1979.

3. Piyaratn P. Basic minimum needs: concepts and practice. Chap. 6 in: Winichagoon P. Kachondham K, Attig G. Tontisirin K, eds. Integrating food and nutrition into development: Thailand experiences and future vision. Bangkok: Institute of Nutrition, Mahidol University at Salaya; UNICEF/EAPRO, 1992:63-70

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