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AMORN NONDASUTA, PIROTE NINGSANON, PRAMUKH
CHANDAVIMOL, and PUANGTONG TANTlWONGSE
Ministry of Public Health, Bangkok, Thailand
PRIMARY HEALTH CARE IN THAILAND
The problem of under-utilization of health centres and hospitals in rural Thailand led to the initiation of a pilot project on primary health care (PHC) in Sarapee District, Chiang Mai Province, in 1969. The project was designed mainly to extend various health services to cover a greater portion of the population in the area. The initial estimation for coverage of existing health services was below 20 per cent of the total population at that time. Recognizing that the health-service delivery structure was not covering all the health and medical demands of the community, the project organizers' strategy was to train people selected by the community to function as intermediaries between the peripheral tambon (community of villages) health officers and the community, adding to the existing health-service delivery on a voluntary basis.
Evaluation of the pilot project revealed that there was increased coverage of the population with basic services. Since then, several pilot projects have been carried out in other parts of the country and the results have been satisfactory. Studies have also been done on various aspects of the volunteer service, such as the method of selection, the types of people who are best suited to perform health services on a volunteer basis, etc. The experience gained from these studies led to the development of a nationwide programme of primary health care in 1977.
THE CONCEPT OF PHC IN THAILAND
The concept of PHC in Thailand has been developed from the country's experience in solving the health problems of underserved people in the rural areas. The concept of community participation - consisting of the contribution of ideas, manpower, money, and materials by the community - is fundamental and provides the key to the success of the PHC programme. To educate a community to be self-reliant or self-supportive is another basic concept that the programme fosters. The Ministry of Public Health (MOPH) is aware that the strengthening of a health-services delivery system and development of a referral system is essential to support the PHC activities.
In the National Seminar on Health for All by the Year 2000, conducted in December 1979, it was decided that primary health-care activities should comprise the following elements: (1) health education; (2) local endemic disease control; (3) maternal and child care, including family planning; (4) immunization against communicable diseases; (5) provision of essential drugs; (6) treatment of common diseases; (7) nutrition promotion; and (8) sanitation and safe water supply.
Furthermore, the participants in the seminar felt that PHC activities could be changed according to community awareness of the problems to be solved. Because health is only one part of development, other aspects such as education, agriculture, community development, etc., should also be considered.
OBJECTIVES OF THE PHC PROGRAMME
The objectives of the programme, formulated on the basis of various concepts, were:
PRIMARY HEALTH-CARE WORKERS
Based on experience in Thailand, it is recognized that potential human resources exist in the community and are waiting to be mobilized. Two types of primary health-care workers have thus been developed: village health communicators (VHCs) and village health volunteers (VHVs), who promote rural health and other development efforts through an organized community. The VHCs are responsible for a cluster of 8 to 15 households, the VHVs for the whole village. The functions of VHCs are to impart health education (prevention and promotion), and to disseminate and obtain health information from the villagers. The VHVs perform the same functions as VHCs, but also have the duty of caring for people who have had simple accidents or injuries and those with common diseases.
Both VHCs and VHVs work on a voluntary basis. However, the government provides them with free medical services and a certificate when their training is completed. Other intangible incentives such as recognition from their peer group are also present.
SELECTION OF PRIMARY HEALTH-CARE WORKERS (VHVS AND VHCS)
To prevent a high drop-out rate for PHC workers, proper procedures for selection are critical. Community preparation prior to selection is necessary. A simplified house-tohouse survey proved suitable for identifying the right people.
TRAINING OF PHC WORKERS
An informal five-day training course for VHCs, covering the use of self-instruction modules, health problem identification, team working, etc., is organized by subdistrict health personnel. The 35 self-instruction modules for VHCs cover curative, preventive, and promotive measures. The VHCs are expected to be able to disseminate such knowledge and gather information from villagers. VHVs obtain 17 additional modules on simple curative care and are trained for an additional two weeks.
When the programme was first implemented nationally in 1981, a training scheme extending from the central MOPH to the peripheral level was developed (fig. 1)
The central trainers are staff members of the MOPH trained in the principles of teaching and learning, using 7 modules on self-teaching and learning. These trainers then developed simplified modules for training the provincial and district trainers and became involved in curriculum planning and training of VHCs and VHVs.
The provincial/district trainers consisted of provincial health staff from the training section and one staff member from each district health office. This team was responsible for training tambon health personnel to conduct the training of VHCs and VHVs.
Fig. 1. Plan for training the trainers at different levels.
Fig. 2. Health service network.
SUPERVISION AND SUPPORT
The Office of Primary Health Care in the Ministry of Public Health is responsible for supervision and support of the PHC programme through the existing health infrastructure (fig. 2)
The purpose of supervision is to strengthen the performance of personnel and volunteers at all levels in order to achieve the goals of PHC. The scope of supervision includes programme planning and monitoring, continuing education, provision of material supports, and selection of VHVs and VHCs.
Supervision of the district level by the provincial level is scheduled three times a year, as is supervision from district to subdistrict level; from district level to VHVs and VHCs no fewer than three villages per district are sampled.
The overall organizational framework of PHC is illustrated in figure 3.
NUTRITION FOR HEALTH AND GROWTH
Nutrition, as one of the elements of PHC, is a major determinant of health and growth. Nutrition and health are not synonymous, but without good nutrition health cannot be optimum.
The consequences of food and nutrition processes and their relation to health are shown in figure 4.
In 1960, the first National Nutrition Survey was conducted by a joint Thai-American team, the Interdepartmental Committee on Nutrition for National Defense (ICNND). The results showed that the civilian population consumed 100 kcal per day below the average requirement of 1,871 kcal. Anaemia and iodine deficiency (goitre) were commonly found. A survey in 1982 still showed a high prevalence of malnutrition, despite several programmes implemented to eradicate nutritional problems.
In a review of past experience, the following factors were found to be the major constraints:
Fig. 3. Organization of PHC programme.
Fig. 4. Food and nutrition in relation to health.
Existing Health Delivery System
During the past 40 years, health delivery in Thailand was based on the Western concept of having a centre for treatment. It was found that only 20 per cent of the population was served by this system. A midwifery centre existed in only 4 per cent of the villages and a health station in 8 per cent. Mobile clinics have been an alternative giving more outreach, but are limited by logistics problems.
Lack of Community Awareness
Thinness and small body size are perceived as normal by rural villagers. Therefore, the involvement of the community in nutrition programmes has been minimal. Furthermore, improvement in a child's nutritional status is neither apparent nor rapid and may require a change in infant feeding practices.
Lack of Multi-sectoral Involvement in the Programme
Nutrition programmes have been viewed as the health sector's responsibility. Though the multidisciplinary nature of the nutrition programmes is realized, collaboration among various sectors has been limited. A National Food and Nutrition Committee was formed in 1970 to initiate such collaboration, but it has not yet been achieved.
A pilot study on Innovative Village Nutrition Activities was conducted in 90 villages in three north-eastern provinces. A simple weighing technique and growth charts were found to be very good tools for problem identification and led to community participation in other nutrition activities, such as nutrition education, locally produced supplementary food, self-monitoring feeding stations, etc. These activities proved feasible for villagers, VHVs, and VHCs. Therefore, it was decided in the current Fifth National Economic and Social Development Plan (NESDP) (1982-1986.) to make a policy of implementing nutrition programmes in the context of PHC.
NUTRITION IN PRIMARY HEALTH CARE
Implementation of PHC programmes since 1977 depended on the activities of "medical cooperatives" at the village level. Villagers perceived this as serving their needs (felt needs), and it helped them gain managerial skills in establishing the village health fund. The stability of the cooperatives appeared to depend greatly on the involvement of villagers through their contributions both in cash and in kind. A similar strategy has therefore been applied to initiate nutrition in PHC, detailed as follows.
Problem Identification
A simple problem-identification procedure and a village nutrition surveillance system (fig. 5) have been launched and have successfully initiated community participation.
A simple weighing scale and uncomplicated, attractive growth charts, which could be calculated and interpreted by villagers, were used. Between 1979 and 1983, over 2 million infants and pre-school children were weighed at least once. A group growth chart was developed for VHCs and VHVs, and is used for the presentation of the results and as a monitoring tool. The addition of pictures of children in different nutritional states also helped the villagers to relate weighing to the appearance of the child.
Fig. 5. The village surveillance programme.
Problem-solving Alternatives
A food and nutrition problem-solving programme, described below, was developed to meet community needs in tackling problems.
The Target Group
The main target group is limited to children under five years old with second- and third-degree malnutrition. The goal was to eradicate all third-degree malnutrition and reduce second-degree malnutrition by half.
Food Supplementation Action
Supplementary food, consisting of rice, legumes, and sesame, was formulated by the Nutrition Division and Institute of Nutrition, Mahidol University. The formulas vary depending on locally available raw ingredients. The purpose is to supplement calories and protein in the habitual diets of children of six months to five years old. Simple processing equipment and an easy method were developed. The food has been well accepted by the target groups and the processing can be done easily by villagers.
Creation of a Village Nutrition Fund
During the course of nutrition programme implementation, it was found that motivation was needed to promote food-processing. Concern for the malnutrition problem and its consequences was one such motivation. Another very effective incentive was the economic one, that is, selling the food produced to nearby communities where food processing did not exist. This led to the initiation of the village nutrition fund scheme (fig. 6).
The process starts with a government contribution of 3,000 baht ($1 = 18-23 baht) per village to buy supplementary food, which is given to the village committee for free distribution to second- and third-degree malnourished children. The organization is similar to "medical cooperatives." People are required to contribute in cash, raw food materials, or labour, in addition to the government endowment. The production of supplementary food is also promoted for sale to the general population. The income as well as the initial community and government contributions generate the "village nutrition fund" that will support the food supplementation programme as an ongoing process. The fund will also provide supplementary food free to severely malnourished children after the initial government support has ended. This is another important milestone in the Thai Primary Health-Care Programme Involving community welfare action.
The community can also generate feeding-station activities for searching for and testing appropriate supplementary food formulas. The most important step is to generate three essential elements at the village level in the nutrition programme, as shown in figure 7. Lack of any one of the three can lead to the failure of the programme.
Fig. 7. The three essential elements for a village nutrition programme.
The results from both the modelling period of the Viilage Innovative Nutrition Activities and the nationwide implementation showed that this new approach is successful, as measured by the improvement in the nutritional status of the children. From the latest survey in July/August 1983 by the Nutrition Division, supplementary food production funds have been established in many of the targeted villages. These amount to 1,668 food production units and 958 nutrition funds.
Nutrition Education
The nutrition education objective has changed from attempting to teach all of the population basic nutritional knowledge to concentration on pregnant and lactating mothers to increase their management skills in the supplementary food programme.
Fig. 8. Village nutrition activities.
The village committee, the VHV/VHCs, and other volunteers are trained and given the responsibility of spreading nutritional messages in the community by means of self-learning packages, manuals, posters, flip charts, and other printed materials.
Overall nutrition activities in PHC are summarized in figure 8.
The Multi-sectoral Collaboration Approach
The conceptual framework in food and nutrition activities for each of the four community
development-related ministries was formulated and put into operation with multi-sectoral collaboration in 1981, as shown in table 1.
OTHER DEFICIENCY DISEASES IN PRIMARY HEALTH CARE
For iron deficiency anaemia and endemic goitre, a study from Leoi Province confirmed the utilization of iodine- and iron-fortified salt as the most appropriate method for approaching the rural poor, because salt is consumed daily by this population. The problem is lack of total coverage with fortified salt and the increasing trend to consume locally produced rock salt. The approach has now been changed and incorporated into the primary health-care system. The fortification technique has been simplified for the VHV/VHCs, and local fortification by the VHV/VHCs, with linkage to the existing village medical co-operatives and village funds, began in fiscal 1984. Details are presented in figure 9.
Table 1. Community food and nutrition activities
| Sector | Major responsible area | Minor responsible area |
| Villagers | Attend
the weighing activity Attend the feeding station Attend the food production activity Feed supplementary food to the malnourished child Share in the nutrition fund |
|
| Village committee | Plan and monitor the village food and nutrition activities | |
| VHV/VHC/others | Organize and implement the village food and nutrition activities | |
| Tambon health officer | Supply
and support nutrition surveillance action Give health/nutrition education Support in organizing the village nutrition fund and supplementary food distribution |
Food processing |
| Tambon agricultural extension officer | Promote agricultural food production | Nutritional education |
| Home economist | Nutritional
education Food-processing demonstration |
|
| Primary education teacher | Nutritional education |
BOTTOM-UP PLANNING AND THE POVERTY ERADICATION PROGRAMME
In the present NESDP, a new planning system aims at the encouragement of bottom-up planning. The focal point in planning at each level has been strengthened by a systematic orientation and training programme. The whole structure is summarized in figure 10.
The tambon council and the village committee are purely commtnity organizations. Requests from the villagers will be gathered and integrated, and priorities set at the tambon council. The tambon development plan will be submitted to the district development committee for integration and priority setting, and then submitted as the district development plan to the provincial development committee for the final check and integration.
The provincial development plan will be submitted to the National Rural Development Committee for final approval. At the tambon level, officers from all sectors are in the tambon development working group, which is responsible for giving technical support to the developmental programme of the tambon council and village committee.
There were 12,555 villages identified as poverty-stricken by the National Rural Development Committee in 1982. A National Poverty Eradication Programme has been formulated and is being operated with the goal of total coverage of the poverty area by 1986. The programme includes the nutrition programme and other agricultural food production programmes such as poultry, vegetables, legumes, fruits, sesame, and fish. This enhances the capability of the nutrition programme to cover more targeted villages in the present NESDP (1982-1986); it is expected that 40 per cent of the villages (26,000 villages) will be covered. In conclusion, for each targeted village, the support will be:
Fig. 9. The local iodine- and iron-fortified-salt approach.
Altogether, each village will have an average unit-cost governmental investment of 6,000 baht.
FURTHER PROGRESSION OF THE THAI NUTRITION PROGRAMME THROUGH THE PRIMARY HEALTH-CARE APPROACH
The nutrition programme, when incorporated into the primary health-care approach, has also clearly shown the way for collaborative action from other governmental sectors and the community (fig. 11). As the programme progresses to the stage of self-supplementation and distribution, its integration into the existing community structure, such as the village co-operatives, should be closely monitored by both the village committee and the tambon officers to assure that distribution is directed towards the malnourished children and that the profit goes to the community. Clear instructions on how to maintain quality by monitoring, i.e. sampling and checking each production lot, will assure the success of the supplementation programme.
Fig. 10. The planning structure of the Fifth NESDP.
The generation of the village fund is the first step in this expansion of the programme toward other community development programmes, and the free distribution of the supplementary food will provide a model for other community welfare action. The holistic concept of self-reliance in the nutrition programme, starting from self-recognition of the problem, self-planning, and problem-solving with a self monitoring system, will give villagers a complete pilot model. and may be applicable to other community development programmes, for example those using the Basic Minimum Needs of Thai People as indicators.
Fig.11. Conceptualized framework for nutrition programme in primary health care.
