History Perspectives
The National Food and Nutrition Policies and Programmes
Nutrition-Related Policy and Health Development
Growth Monitoring for the Under Fives
Food and nutrition surveillance system (FNSS)
Other Important Nutrition Interventions
Early Period (before 1960)
Gathering Momentum: Pre-National Food and Nutrition Plans Period (1961-1976)
Thailand has been blessed as "the land of bounty", and famine or hunger has rarely been mentioned throughout her history. This was vividly reflected in a famous inscription stone during the Sukhotai period (1200-1400): "In the water we have fish; in the paddies we have rice." Abundant food from the fertile rice-growing central river delta was accompanied by low population growth. The population of Thailand and its growth remained quite low even during the first half of this century: 8.2 million in 1910, 9.2 million in 1919, and 11.5 million in 1929. However, despite the low population density and relative abundance of food, there is reason to believe that the quality of the average Thai diet must have been low over a long period of time, in particular with regards to protein consumption. The height-for-age of Thai children, when compared with North American references shows that Thai children lag behind their counterparts53. This may be due to the food habits and traditional diet of the Thai people: predominantly rice with very little consumption of other higher quality foods such as animal proteins. It was not until after the Second World War (late 1940s) that Thailand started her demographic transition through the impact of public health measures and socio-economic development. The population began to increase rapidly as anticipated during the first phase of the transition. The population reached 26.2 million by 1960 and 34.4 million by 197054 and began to slow down in the 1980's. This increase gave rise to social and economic pressures, including deforestation, ecological degradation, urban migration, and the emergence of mass poverty and malnutrition.
53. Khanjanasthiti P, et al. Growth of Infants and Preschool Children. J Med Assoc Thai 1973;56(2):88-100.It can be said that nutrition activities began in 1926 when the Ministry of Interior at the Department of Public Health established a Nutrition Section chaired by Dr. Yong Chutima. The section was re-organized many times during the following 40 years. First, it was joined with the Division of Food and Medicine, Ministry of Public Health (MOPH) during 1942-1953. Later on, this division was divided into the Division of Food Promotion and the Division of Medicine. Since 1963, the Division of Food Promotion has been renamed the Division of Nutrition in the Department of Health.54. Porapakkham Y. Mortality and Health Issues: Levels and Trends of Mortality in Thailand. Asian Population Studies Series No. 77. ESCAP, United Nations, Bangkok, 1986.
From the inception of the Nutrition Section until the 1950s, this division took the leading role in nutrition activities for both clinical and public health purposes. During the long tenure of Dr. Yong Chutima, the first director of the Nutrition Section and later the Food Promotion Division (1926-1960), a variety of food and nutrition activities - such as the use of high protein food supplementation for patients in the Central Hospital and the Siriraj's Hospital School of Medicine in Bangkok - were initiated55. A nationwide nutrition education campaign was also launched by Prime-Minister General Piboonsongkram in 1937 which advised Thai people to eat nutritionally balanced foods based on the 5 food groups. A promotional song was composed to help deliver the messages. Information was also given on appropriate combinations of foods, and there was promotion of soybean milk, desserts and other products56.
55. Ministry of Public Health. Nutrition in Primary Health Care. Bangkok: The Royal Thai Government: Ministry of Public Health, 1984.During the same period, nutrition managed to find its niche in medical education at the University of the Medical Science (now Mahidol University) pioneered by Professor Dr. Choedchalong Naetsiri who integrated nutrition topics such as infant feeding, infant and child nutrition, and clinical nutrition into the medical and nursing curriculum. She also modified local foods for use as supplementary food for infants, and played an important part in encouraging medical students to become more interested in nutrition. Professor Dr. Amara Chantarapanon who was responsible for creating the Department of Nutrition within the Faculty of Public Health, was also wrote the first book on nutritional sciences in the Thai language. Nutrition was later included in other colleges, especially as part of home economics training.56. Valyasevi A. Nutrition in Thailand: Past, Present and Furture. In: Wichaidit S, Thanpaichitr W, and Srianujata S, eds. Applied Nutrition. Bangkok: Brayoonwong Press. 1986. (Thai).
Dietary surveys were conducted as early as 1931 with the assistance of foreign nutritional experts. Zimmerman found that although there were no serious dietary deficiencies, diets were mostly rice and fish with very little meat, dairy products and fat. In 1934-1935, the Siam Second Rural Economic Survey was carried out by Andrews. He found that the impact of the 1932 economic depression on food expenditure was obvious but there was little evidence of actual dietary deficiency except the lack of variety in the North and the North-east57.
57. Zimmerman (1931) and Andrews (1935). Cited in Konjing K, Veerakitpanich M. Food Consumption and Nutrition in Thailand. In: Panayotou T, ed. Food Policy Analysis in Thailand. New York: Agricultural Development Council, 1985:157-187.
Rapid economic growth and infrastructure build-up in Thailand commenced in the 1960s propelled by the First National Economic and Social Development Plan (NESDP) initiated in 1961. Between the years 1960 and 1970, development programmes in Thailand led to a rapid annual rate of growth in the GNP, averaging 8.4% which is well above the average 5.8% for other middle-income countries during this period reported by the World Bank. This increase in national wealth, together with the development of better defined and organized government interventions due to central planning, may have enabled the later expansion of interest into public welfare programmes, including nutrition and health. But during the period of the First NESDP (1961-1965) and the Second NESDP (1966-1971), there was less inclination towards social development. Concepts of social development and know how were somewhat vague in the minds of not only economists and planners but health professionals as well. Nutrition problems were considered the responsibility of the health sector, and were dealt with primarily by curative health treatment. Thus, the First, Second and Third NESDPs (1961-1976) followed the health approach stressing remedial actions in the medical institutions58. However, there was increasing concern for such problems among researchers and public health workers as reflected in some publications from the late 1950s and early 1960s. Descriptive statistics on nutrient deficiency conditions such as beri-beri and anaemia collected from hospital-based records showed that the problems were quite widespread, but the magnitude was unknown.
58. Unakul S. An Economic Planner's View of the Nutrition Problem in Thailand. In: Panayotou T, ed. Food Policy Analysis in Thailand. New York: Agricultural Development Council, 1985:157-187.To get nutrition recognized as a major national problem needing concerted efforts to find a solution took years, before policy direction was obtained from the National Economic and Social Development Plans. There were certain developmental processes that helped in gaining momentum.
First, there was a carefully planned national nutrition survey conducted in 1960 by a team of Thai and United States experts36. The report of the survey was published by the U.S. Interdepartmental Committee on Nutrition for National Defence which had been involved in the conduct of similar surveys in 15 other countries. This survey has been a landmark in the development of public and government awareness of the nutrition problem in Thailand. The survey not only revealed that undernutrition and nutritional deficiencies were serious and widespread public health problems but also inspired a number of nutrition scientists to shift from pure academic interest in nutrition research to work with other professions and people to solve the country's nutrition problems. Some of the major findings in this survey were as follows:
- Protein-energy malnutrition was the most severe problem, especially among pregnant and lactating women, infants, and preschool children in poor urban or rural areas.Among the specific recommendations included in the report was the better co-ordination of (i) the different activities related to nutrition such as those of the Nutrition Division of the Ministry of Public Health; (ii) the teaching and research activities of the School of Public Health and the medical schools; (iii) the food and beverage laboratories of the Ministry of Industries; and (iv) the development activities of the Processed Food Organization and the Army Quartermaster Subsistence Division.- Vitamin A, thiamin, and riboflavin deficiencies and iodine-deficiency goitre were found in the northern and north-eastern regions.
- Anaemia was also high, but the aetiology was not clear. Dietary intake of iron was high (but the issue of bio-availability was not known at the time).
- A high prevalence of urinary bladder stone disease, a disease whose cause was then unknown, was found in the northern and north-eastern regions.
Second, there was the Expanded Nutrition Project, a pilot project initiated in March 1961 in 10 villages in the north-eastern province of Ubon Ratchathani. This project was later called an ANP and was conducted by several co-operating ministries, with support from WHO, FAO, and UNICEF. In fact, the project was influenced by Applied Nutrition Programme jointly developed by WHO and FAO to increase the impact of programme activities in nutrition, recognizing the failure of the implementation of supplementary feeding programmes based on donated supplies. The key aims were to encourage and mobilize rural communities to grow and use local food more to improve their diets, and the co-operation and co-ordination between various disciplines including health, agriculture, education and community development. However, it was still based on the rather restricted view that malnutrition was fundamentally a food problem, and thus emphasized the development of high protein foods. Community participation in the decision making process was quite limited.
The Thai ANP experience included the development by the Division of Nutrition, MOPH of nutritious family dishes based on high-protein foods like soybeans and other legume derivatives. Local schools also participated in the project including screening for malnourished children, vitamin A supplementation, and combined nutrition and health education. Nutrition promotion slogans were also designed, for example, "Human milk for the human baby", and "One egg a day makes a physically strong body"59. The project received international publicity for its success, but there were no data about its impact on the nutritional status of the target group. However, the project has been regarded as one of the antecedent movements that led to collaboration among various ministries in the development of the national food and nutrition policy later on.
59. Ministry of Public Health. Nutrition in Primary Health Care. Bangkok: The Royal Thai Government: Ministry of Public Health, 1984.Third, the National Economic and Social Development Board recognized the multi-facetted causality of nutrition problem during the Third NESDP (1972-1976) and created venues and forums for the interchange of ideas among officers from various ministries. Many food and nutrition seminars and meetings were organized and supported by the government and international agencies i.e. UNICEF, WHO and FAO. One of the most important meetings was an Interministerial Workshop held during 14-21 February 1973 supported by UNICEF and USAID in co-operation with the MOPH60. The objectives of this meeting were to review information on existing or proposed nutrition programmes within the Third NESDP (1972-1976); and to prepare guidelines for the development of a National Nutrition Policy which was to be submitted to the National Economic and Social Development Board (NESDB). The outcome of the meeting also made it clear that the improvement of nutritional status of the population should be viewed as an investment, not an expense, and that the stock of future manpower was at stake. Malnutrition is not a health problem, but an outcome of social disparity. The problem must be addressed beyond the health sector. The most important point made was that the national planning authority should take responsibility for planning and coordinating the food and nutrition policy in line with national development policy. These recommendations were sent to the NESDB as the "Report for the Development of National Food and Policy Guidelines for Thailand". These recommendations were accepted and thus contributed to the creation of the First National Food and Nutrition Plan.
60. Subcommittee on Food and Nutrition Planning. National Food and Nutrition Policy. Bangkok: The Royal Thai Government; Office of the National Economic and Social Development Board, 1975.During this developmental process, a critical mass of experts from various ministries and universities were identified and organized into a task force under the auspices of the NESDB. The responsibility was to formulate the First National Food and Nutrition Plan to be incorporated in the Fourth NESDP61. In order to train the next generation and to strengthen the existing personnel for future tasks, many short and long term scholarships were awarded to study on food and nutrition planning abroad under the sponsorship of MOPH, UNICEF and WHO etc.
61. Nondasuta A. Thailand Food and Nutrition Planning and Programme. Proceedings of the Special Nutrition Study Seminar for Policy Makers and High level Officers in Nutrition Programmes, 25-30 November 1991. Institute of Nutrition, Mahidol University, Thailand, 1991.Fourth, there was strong support from multi-lateral and bi-lateral agencies as mentioned earlier. The United States Agency for International Development through its Nutrition Division also made available to the Thai government a technical advisor, Dr. Nevin Scrimshaw. In close co-operation with USAID, a working group was appointed by the Sub-committee on Food and Nutrition. Planning by the NESDB produced a document entitled Technical Information and Base-line Data for the Formulation of a National Plan on Food and Nutrition Development". The document analyzed and addressed the seriousness of the food and nutrition problems in Thailand. Multiple causes of malnutrition were outlined, including health, nutrition, demographic, and socio-economic factors. The document was very influential as it helped to communicate the information to policy makers and was used as a basis for the first Food and Nutrition Plan.
In summary, during this preparatory phase before the First National Food and Nutrition Plan, nutrition problems and target groups were identified and prioritized, pilot projects were tested, a critical mass in terms of manpower in various ministries was formed, and tremendous international support obtained.
The First NFNP during the Fourth NESDP: Multi-sectoral Approach
The Second NFNP in the Fifth NESDP: Nutrition Programmes through Primary Health Care and Poverty Alleviation Policy
The Third NFNP in the Sixth NESDP: Nutrition Programmes as an Integral Part of the Basic Minimum Needs and Quality of Life Movement
Figure 1 laid out the time frame of the National Food and Nutrition Policy (NFNP) in Thailand along with other policies related to NFNP. The first two NESDP in fact concentrated their efforts on building the country's infrastructure, including transportation, communication systems, schools, and basic public services such as electricity, piped water, etc., with the aim of providing the basic physical infrastructure. The social aspect was not included until the third NESDP, in which family planning was the main social entity.
Although the Third NESDP did not address malnutrition, it did acknowledge that the nutritional status of the population was important to the country's development and deserved attention. In response to that concern, the MOPH submitted a health plan that included the first proposal for a food and nutrition plan. The plan was targeted primarily on infants and preschool children and, to a lesser extent, on school-aged children. The major activity was providing high-protein foods to the younger groups at risk. Activities directed at infants and preschool children were carried out at child nutrition centres newly created by MOPH, while primary schools handled programmes for school-age children.
Evaluation of programmes during the third NESDP showed that the nutrition programmes reached only 0.6% of children estimated to be malnourished. This scant coverage was attributed to limited funds and to lack of co-ordination among agencies62. However, evaluation of the third NESDP did provide a summary of technical and baseline data used to develop the first National Food and Nutrition Plan for the fourth NESDP.
62. National Economic and Social Development Board. The Fourth National Economic and Social Development Plan (1977-1981). Bangkok, Thailand: Office of the Prime Minister, Government of Thailand. 1977.
Historically, Thailand's nutrition programmes have been components of health plans. Until 1977, the First National Food and Nutrition Plan (NFNP) was included as part of the Fourth National Economic and Social Development Plan (NESDP) (1977-1981). Since it was clear that malnutrition was a multifaceted problem, the multi-sectoral approach was devised. Thus, a National Food and Nutrition Committee was appointed, consisting of members representing various ministries, especially the four major ministries, namely agriculture, education, interior (community development) and health. A committee at provincial level with a similar composition was also appointed.
The first NFNP listed seven major nutrition problems: protein-energy malnutrition, iron-deficiency anaemia, vitamin A deficiency, beri-beri from thiamin deficiency, goitre caused by iodine deficiency, angular stomatitis induced by riboflavin deficiency, and urinary bladder stone disease resulting from phosphorous deficiency. Protein-energy malnutrition was considered the most significant and a priority problem because of its high prevalence, especially among pregnant and lactating women and preschool and school-aged children. Possible causes were identified as inadequate food production for household consumption; inefficient and inequitable food market systems; 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 nutritional status of the population by tackling the problem from many angles, i.e., improvement of health care and hygiene; increasing food availability; nutrition education; and improving socio-economic conditions of the vulnerable groups. The plan targeted rural infants, preschool children (children under five), pregnant and lactating women, and, to a lesser extent, school children. (See Annex 1 for the details).
Although both short and long term strategies and activities were formulated, short-term action to remedy severe and moderate malnutrition was the priority, by feeding children high-protein supplements at Child Nutrition Centres (approximately 1,200 were constructed)63. These foods were centrally produced and supplied through the health system to the periphery. Home delivery of supplementary foods was provided for children with severe malnutrition.
63. Tantiwonge P, Santikitrungruang C, Withyametha B. National Nutrition Policy and Nutrition Programme in Thailand (1982-1986). Proceeding of the Fifth Food and Nutrition Planning Workshop, April 21-25, 1986, University of the Philippines at Los Banos, Philippines. 1986:103-118.In reality, the nutrition programme was not fully implemented due to lack of inter and intra sectoral collaboration. Although some action plans were well defined, planning was entirely a top down approach. The planning, authorization and budget allocation were decided from the central or provincial level and vertically channeled to the grassroots, but no single agency was responsible for overall co-ordination and monitoring of programmes. There was no change in the programme planning and budget allocation structure to support multisectoral efforts. There was very little participation by the community. Many of the activities did not achieve the set objectives and depended totally on government-provided services, for example, the centrally produced supplementary food, and the nutrition rehabilitation in the villages.
It was not surprising that the first NFNP produced disappointing results. Malnutrition continued to be a serious problem, especially protein-energy malnutrition among infants and preschool children and iron-deficiency anaemia among children and pregnant and lactating women64. A 1980 nationwide survey showed that 53% of preschool children suffered from protein-energy malnutrition. However, the most significant accomplishment of this plan was the creation of a strong awareness of the nutritional problems both among the public and private sectors and at all levels, and led to a strong political commitment to the country's policy.
64. National Economic and Social Development Board. The Fifth National Economic and Social Development Plan (1982-1986). Bangkok, Thailand: The Royal Thai Government, 1981.
The Fifth NESDP continued to include the food and nutrition plan. However, the concept and approach in planning changed. Malnutrition was recognized instead as a manifestation of poverty and ignorance. Therefore, poverty had to be eradicated. Nutrition programmes employed during the Fourth NESDP were seen as only stop-gap measures to relieve the most severe forms of malnutrition until more systematic solutions could be developed.
As in the First NFNP, the main target groups for nutrition programmes were infants and preschool children and pregnant and lactating women; however, this plan increased the attention given to school children. The goals in the Second NFNP were also more quantifiable in terms of elimination of severe malnutrition in target groups: to reduce moderate malnutrition by 50% and mild malnutrition by 25% in infants and preschool children, and to reduce protein-energy malnutrition by 50% in school-aged children. (See Annex 2 for the details)
The main thrust of the Fifth Plan's nutrition policy lay in the broader policy of poverty alleviation and development of backward areas (PAP), and the primary health care approach (PHC). The details and concepts will be presented later in sections 8.3.1 and 8.3.2. This was the important turning point in the developmental approach in the country, which had used to focus attention on overall economic growth and its trickle down effects on rural development.
The success in the implementation of the community-based nutrition programmes has been strengthened and accelerated by the long term policy to achieve health for all by the year 2000. Both PAP and PHC policies have nutrition concerns as a component. The rural poverty alleviation policy defined poverty areas as needing urgent attention instead of setting unrealistic nationwide goals. 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, the plan provided focal areas for all implementation agencies for the integration and co-ordination of activities in rural development both at central and rural levels. Under the PAP, all activities were directed to 288 districts in 38 provinces which were identified as the priority areas for implementation. All sectors involved had to direct their efforts to these communities. The major ministries - Health, Agriculture, Education, and Interior integrated their activities through committees at each level, serving as trainers, programme supervisors, or proposal developers. Multi-sectoral collaboration was also promoted through community-level training sessions involving personnel from each sector. Thus, village organization and planning at the community level were strengthened. These bottom-up efforts appeared to function more effectively, to promote greater integration of the efforts of the various government sectors, and to use the potential of the community - through village committees - to address needs and possible solutions. In addition, there was an organizational change for rural development by having only one national committee instead of too many sectoral developmental committees in charge of development policies, with infrastructure down to the village level. This was a striking organizational reform which 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.
The PHC concept emphasizes community self-reliance. Therefore, manpower development, management and community financing were facilitated. Village-based health volunteers called village health communicators (VHC) and village health volunteers (VHV) were trained nationwide. Growth monitoring programmes were 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 VHV and VHC were responsible for weighing, interpreting and communicating the results to mothers. The moderately and severely malnourished children received more attention, and their mothers were encouraged to participate in the activities. Supplementary food programmes were also financed through the MOPH, which introduced economic incentives by establishing village nutrition funds. Under this plan, MOPH provided target villages with a fixed amount of seed money for community efforts to improve nutrition. The community also determined whether the funding would assist people with immediate needs for supplementary foods (poor families with malnourished children) or would go towards starting a local supplementary food production unit. Development of village-based supplementary food processing allowed the communities to become self-reliant. Through these strategies, the community participation improved and people took more active roles in solving the problems within their own community.
Thus, the Second NFNP integrated nutrition into the Primary Health Care Plan, focusing on areas targeted by the Rural Development Plan. Specific nutrition 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 (1982-1986), the nutrition situation of infants and preschool children had been dramatically improved, and severe PEM had practically been eliminated and only a small amount of moderate PEM remained. Weighing by simple beam balance and the use of growth charts by the village-based health volunteers (VHV and VHC, trained under the PHC strategy) and mothers were shown to be feasible and used for problem identification. Simple technology for village level processing of supplementary food was promoted to overcome the disruptive distribution of centrally produced supplementary food. Village self-financing schemes were also tried with some success.
The third NFNP, incorporated into the sixth NESDP, continued to use Primary Health Care, with multisectoral collaboration for planning and implementation. Target groups for the Third NFNP were the same as for the previous two, except that wage labourers and the elderly were added. Nutrition activities included developing more sensitive indicators for nutrition surveillance and growth monitoring; conducting nutrition education for behavioural changes; encouraging interdisciplinary research in food and nutrition; and promoting community self-financing with the merger of various Primary Health Care funds into a multi-purpose village fund. (See Annex 3 for the details).
The concept of "having a better quality of life" was introduced to replace that of "having good health". The quality of life concept was translated into action via the "basic minimum needs" approach and was implemented as a pilot trial under the PAP scheme in 1983. Improvement in the quality of life was the central goal during this period of the NESDP. The BMN approach provided the same tools for identifying problems, monitoring progress and evaluating the steps taken towards a better quality of life. Simple and practical indicators, understood and measurable by the villagers were developed. Eight main categories of the BMN indicators were used.
The important feature of this NFNP was the basic minimum needs approach to improve community participation and integration of sectoral development activities. In the Sixth NESDP, similar strategies for nutrition continued and the basic minimum needs approach was implemented nationwide to strengthen the integration of sectoral efforts. Birth weight and weight-for-age of underfives and school-aged children were the nutritional 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 villagers would increase their understanding and have confidence to participate. In these processes, local officers were expected to change their roles from being the agents of change to the facilitators or advisers.
By 1989, more than 500,000 village health communicators (VHC) and 50,000 village health volunteers (VHV) were trained, covering almost all the villages in the country. At the end of the Sixth NESDP, the most recent nutritional surveillance report (1991) has shown that the prevalence of severe malnutrition is almost nil, and moderate malnutrition has reduced sharply.
Poverty Alleviation Plan (PAP)
Primary Health Care Development
Basic Minimum Needs and Quality of Life Movement
Growth Monitoring, and Food and Nutrition Surveillance System (FNSS)
65. National Economic and Social Development Board. Rural Poverty Alleviation Programme, 1982-1986.Based on the report "Rural Development Policies" prepared by the Prime Minister's Advisory Council, the Prime Minister General Prem Tinsulanonda initiated the Poverty Alleviation Plan in 1981. Subsequently, it became a major programme of the Fifth NESDP (1982-1986).66. Tontisirin K and Kiranandana T. Public Policy and Implementation Strategies for Alleviation of Malnutrition and Poverty in Thailand. A paper presented at a meeting on The Financing of Social Services during the 1980's and Policy Options for Next Decade", March 1-3, 1990. UNICEF Office, Florence, Italy.
The objective of the programme was to improve the quality of life for 7.5 million poor in the northern, north-east and southern regions. The PAP was targeted at high poverty concentration areas. Two hundred and eighty-eight districts and subdistricts in 38 provinces of the north-east, north and south were included. It was planned that population living standards would be developed to subsistence level by providing minimum basic services, introducing appropriate technology and gradually transferring responsibilities to the people. Maximum participation by the people was considered fundamental for solving their own problems.
A central co-ordinating organization, "National Rural Development Committee", for rural development was appointed in 1982. This committee soon replaced all other committees involved in rural development prior to 1982 and served as the sole national rural development committee. At the provincial level, there were the Provincial Employment Creation and the Provincial Development Committees. At the district, subdistrict and village level, there was only one development committee at each respective level. Four major ministries, i.e. Health, Agriculture, Education and Interior were the implementing agencies. The activities were integrated and targeted at poor villages through the village committees. Nutrition was implemented as one of the PHC elements by the village-based health volunteers, village committee and villagers themselves. Intersectoral collaboration at the village level was strengthened by an integrated training team, consisting of extension personnel from the four main ministries to facilitate the community activities.
Four key programmes were implemented:
i) Rural job creation programme: Jobs were created for rural people during the dry season to boost their income. Most of the employment was given to people in the locale so that rural people would remain in their communities and participate in community development activities.A system for channelling all information was established. Central data processing was set up at Thammasart university in Bangkok. The same record forms were used in all areas and data reported to the central rural development committee.ii) Village development projects or activities: The activities included village fish ponds, water sources, prevention of epidemic diseases affecting poultry, cattle and buffalo bank, and other development projects focused on rural poor to improve their economic status and household food security.
iii) Provision of basic services: Public services for rural poor such as health facilities and health services, nutrition, clean water supplies, and illiteracy education programmes were directed to the targeted areas.
iv) Agricultural production programme: Important programmes included nutritious food production (especially crops used for supplementary feeding of young children), upland rice improvement projects and soil improvement projects. Income generation and household food security were the direct benefits.
In the Sixth NESDP, the PAP approach continued to be utilized. The plan also concentrated on self-reliance and adjustment to the changing economic conditions and environment67. In this plan, villages were classified into 3 categories:
i) Backward or poor areas defined as villages where people faced 4 or 5 problems of basic needs for their livelihoods, such as poor transport facilities, no land holding for agriculture, low agricultural productivity, and poor health and environmental sanitation. 5,787 villages were in this category and required intensive governmental support as in the PAP areas.The result of this plan from a food and nutrition point of view was quite promising. Rural household food security improved due to the availability of more nutritious foods such as fish, chicken, vegetables and fruit. More than 60,000 families utilized new agricultural technologies and there were 2,655 new village fish ponds at the end of the fifth NESDP. The cattle and buffalo bank was also able to lend animals to 20,000 families. In addition, health services through the primary health care approach had reached more than 80% of the targeted villages. Thus, the PAP must have contributed a certain amount to the reduction of PEM prevalence during the period.ii) Intermediate areas defined as areas facing only one or two problems identified in the poor areas. 35,514 villages were included, and this group of villages required some government inputs.
iii) Advanced areas defined as areas with very few problems and economically better off. 11,621 villages were in this category. They did not necessarily need government inputs, and were encouraged to work with the private sector.
67. National Economic and Social Development Board. Rural Development Plan in the Sixth NESDP 1987-1991.
68. Ministry of Public Health. Nutrition in Primary Health Care. Bangkok: The Royal Thai Government: Ministry of Public Health, 1984.Since Thailand has adopted Primary Health Care (PHC) as its major strategy for health development, it is indeed necessary to highlight its development in parallel with nutrition activities.69. Kachondham Y and Chunharas S. On the precipice: transitions and challenges for Thailand's health development. Nakhonpathom, Institute of Nutrition, Mahidol University at Salaya, 1992.
Thailand's Primary Health care (PHC) initiative began in the 1960's with various community-based health development programmes initiated in different parts of the country. This initiation was driven firstly by a concern about the inadequate coverage of the nation's health service infra-structure. Secondly, but equally important, was the belief in the community's potential for self reliant health care. This also entailed a need to establish an effective interface between the people's efforts and the health service system. Concepts and approaches for improving the community's participation in health and its interface with the health service system have been tested since 1970 in the Saraphi, Lampang and Sa-merng Provincial Projects in northern Thailand, and the Nakorn Rashasima (Korat) Project in the North-east, amongst others. Lessons learnt regarding appropriate health information dissemination took into account people's culture and perceptions, simple curative and preventive care provision, and mobilization of potential local resources (both financial and manpower). These were used to improve approaches to this difficult but healthy strategy70. Riding on the momentum of the Alma-Ata Declaration and the global goal of "Health for all" (HFA) by the year 2000, these experiences were then incorporated and turned into a national PHC programme starting in 1980, which was in the middle of Thailand's 4th National Health Development Plan (1977-1981). The latter's objectives included the following:
- To increase health service coverage and to make basic health services available, accessible and acceptable to people, particularly among the under-served rural population and to help the people to help themselves.PHC in Thailand, at present, is comprised of the original 8 elements cited by the World Health Organization, including education, proper food supply and nutrition, maternal and child care and family planning, adequate and safe water supply and sanitation, immunization, prevention and control of local epidemic diseases, appropriate treatment of common diseases and injuries and availability of essential drugs71. In addition, Thailand has added two other elements, maintenance of mental health and the prevention and control of drug abuse, as well as observance of dental health. Most recently with increasing health concern about various problems which need wider community participation, an additional 4 elements have been added: consumer protection in health; environmental health; substance abuse control; and AIDS prevention.- To utilize community resources and to encourage community participation in order to solve individual health problems and eventually to establish self-help programmes at the village level.
- To promote the dissemination of health information to the people as well as to integrate all the data which reflect the health needs of the communities.
- To promote the health status of the people who live in the rural areas and their own awareness of health problems and problem solving capabilities.
70. Nittayarumphong S. Evolution of Primary Health Care in Thailand: What Policies Worked? Health Policy and Planning 1990; 5(3):246-254.
71. Nondasuta A. The Realization of Primary Health Care in Thailand. Ministry of Public Health, Bangkok, Thailand 1987.Several stages in PHC's gradual development in Thailand over the past decade are evident. There are no clear cut passages from one stage to another, but the concepts and efforts have evolved as follows:
Stage I - Manpower recruitment and community organization development (starting from 1977).
This involved the training of village health volunteers (VHV), village health communicators (VHC) and the villagers themselves to take care of various development activities and to manage the different inputs necessary for achieving improved community and individual well-being. The health personnel were also re-oriented, trained to work with people, and to be better supporters rather than just care providers. The aim was to establish a firm front line of contact with the villagers. Tremendous efforts have been made to ensure that this will develop on a long-term basis by training health centre staff in education techniques and increasing their technical knowledge in health and curative services. As for nutrition activities, VHV and VHC co-ordinated all food and nutrition activities within their villages72. Supervised by health personnel, they carried out growth monitoring activities in the village. Simple beam balance and growth charts, which helped mothers and caretakers to understand the nutritional status of their children were introduced. After each weighing session, the weight-for-age of all children weighed was plotted on a village growth chart. This tool allowed the community to visualize the magnitude of its nutrition problem. As the result of this development, in 1989, there were 588,555 VHCs and 62,075 VHVs in almost every village (98.4%) in the country.
72. Boonyoon D and Chandavimol P. Village-Based Social Development Planning: An Experience from Korat Province Thailand. Bangkok: Ministry of Public Health, 1986.Stage II - Community self-financing evolution and managerial back-up (starting from 1978).
Community financing may take the form of village revolving funds, co-operatives or other types of collective financing schemes with inputs coming mainly from within the community to allow them full responsibility in planning, managing and monitoring their own development. Training and support, however, were provided by the government. Thus MOPH provided target villages with a fixed amount of seed money for community efforts to improve nutrition. The primary requirement was that money would only be dispensed if the community had developed a strategy to generate revolving funds. The community determined whether the funding would assist people with immediate needs for supplementary foods (poor families with malnourished children) or would go towards starting a local supplementary food production unit. Later on, single-purpose financing schemes usually evolved into multi-purpose co-operatives. A further incentive were the matching funds provided by the government and (up to a certain amount) which boosted even further the efforts of the community.
In 1985, the Health Card Scheme was introduced. In this scheme, villagers pay a premium and are issued health cards which entitle them to free medical services when they are in need. The first contact point will be at village level or the nearest health centre where they will be referred upwards, if necessary. Higher level health facilities, i.e. community, general and regional hospitals, allow cardholders to pass through a "green channel" once they have seen and been screened by lower level staff. Within the scheme, the health service system must organize itself in such a way that the first contact/referral point for the villagers will be effective in handling the problem. Further, referral between different levels will be well co-ordinated. In doing this, they receive financial inputs from the community's health card fund. The people themselves are motivated to utilize services according to the referral level, as they are assured that they will be referred to higher levels when they require it. Thus, the Health Card Scheme is not only a form of health insurance. It also aims to ensure that effective referral will take place at all levels and by-passing be kept to the minimum.
Stage III - Infra- and Intersectoral Approaches and Health System Interface (starting from 1983).
Though intersectoral collaboration for health had been emphasized since PHC's very beginning, it was not until the introduction of the basic minimum needs (BMN) approach that it became effective and realistically put into action. The BMN approach encourages a village to establish an information system whereby villagers can collect relevant data to identify their problems concerning their "Basic Minimum Needs" and these do not solely centre on health. Community hospitals are emphasized as an essential link between the lower echelon of health infrastructure and the upper tier i.e. general and regional hospitals (84 presently exist with at least one being located in each province). Community hospital staff including physicians have been trained to ensure that they understand the principles, concepts, planning and implementation of PHC programmes. They are responsible for supervising health centre staff, and making sure that patients are currently referred from the community. They also aid in ensuring that each patient is taken care of promptly and properly in order to foster this channel of communication and co-ordination, rather than encouraging the by-passing of lower level facilities. At the same time, they will make timely and appropriate decisions in referring patients to higher levels of care at general or regional hospitals when necessary.
73. Nondasuta A and Piyaratn P. Basic Minimum Needs. World Health, WHO Publication. June, 1987.To strengthen rural development, during the sixth NESDP, the basic minimum needs approach (BMN) was used as the principle to achieve a good quality of life for rural people. In addition, the approach has been developed as a response to problems encountered in the course of actually implementing PHC programmes and projects. Two major problems were a lack of participatory orientation and the necessary skills among local government workers in promoting and supporting community participation; and inadequate opportunities for villagers to manage their own community development process i.e. data collection, planning and decision making. To overcome these obstacles, an Intersectoral Social Development Project was launched under the auspices of the NESDB in 1981. The project's outcome was a set of Basic Minimum Needs (BMN) and their indices (Annex 4) to be used by the villagers themselves.74. Ministry of Public Health. Basic Minimum Needs and Quality of Life in Development. 1986.
75. Boonyoen D and Chandavimol P. Reorientating Administrative Organization for Village-based Social Development: An Experience from Korat Province, Thailand. Kuala Lumpur, Malaysia: Asian and Pacific Development Center, 1986.
The BMN approach may be succinctly defined as a socially-oriented, community based, intersectoral and scientifically-sound development process. It is also a process carried out by the people and community with support from the government aimed at fulfilling basic human and community needs. Eight groups of BMN indicators (32 measurable indicators) were developed and used as the tools for problem identification and setting up goals for development in the community.
The BMN has been implemented through the rural development infrastructure. It has been implemented throughout the country, although more attention was given to the rural poor areas. The steps and process in the BMN approach are summarized in Figure 2. At the community level, village committees are responsible for the data collection and compilation of each indicator. The data are presented as village aggregates and compared to the criteria of success set out for the scheme. There are 3 BMN forms employed in the process.
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BMN - 1 Form |
is employed to collect data on BMN indicators from each
household. Village committee members are responsible for this process. |
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BMN - 2 Form |
is employed to collect general village level information by
compiling the data collected in BMN-1. |
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BMN - 3 Form |
is the aggregated and summarized form for the planning,
prioritization and decision-making process. This form will also be sent up the
hierarchy and put into a nation-wide, computerized database at the central
level. |
Through this entire process of problem identification, planning, prioritization of the types of activities and support needed, implementation, and evaluation by re-survey of the BMN status of the village, villagers, by themselves, are aware of their own problems and the level of their achievement. At the same time the district and provincial administration are able to effectively carry out their supervisory and supportive tasks and closely interact with villagers in trying to respond to their needs.
At the end of the Sixth NESDP, the crucial factors that contributed to the successful application of the community based BMN approach were identified76. These were:
- appropriate leadership styles and roles, as well as attitudes of responsible government workers at different levels and of community leaders at the village and sub-district level;At present, more than 95% of the total villages throughout the country are using BMN indicators to gauge their development status and achievements. There have been some modifications, especially in some rapidly improved areas. Either new indicators were added or the criteria of success were lifted to a higher level. However, long term success still needs constant and persistent government support. Quality improvement in data collection by the people themselves, enhancing local capacity in planning and management, utilizing MBM indicators and supervision by government officers are important issues for sustainable success.- on-going, but realistic, technical, financial and morale support from relevant ministries and the government;
- long experience of trial and error efforts in community development with a spirit of self-help and a sense of loyalties (esp. community consciousness) among villagers;
- effective management of VC in community development with mobilization and development of adequate an appropriate community resources (i.e., human, financial and technological).
76. Piyaratn P. Quality of Life Development in Thailand. In: the Proceedings of the Special Nutrition Study Seminar for Policy Makers and High Level Officers in Nutrition Programmes, 25-30 November 1991. Institute of Nutrition at Mahidol University, Thailand, 1991.
There are two information systems which are explicitly labelled as food and nutrition or nutrition surveillance. One is the national nutrition surveillance or growth monitoring system for the under-fives and school children compiled by the Division of Nutrition and the Division of School Health, MOPH. The other is the pilot food and nutrition surveillance system (FNSS) implemented by the NESDB in 5 selected provinces in each region of the country in 1990-1991.
Growth Monitoring in Primary School
Strongly committed by the Division of Nutrition of the MOPH with ongoing support from UNICEF, this system claims to cover more than 85% of the nation's rural under-fives. The indicator has been weight for age using the Thai standard (combined sex) established in 197577 and Gomez's classification.
77. Tantiwonge P, et al, Thai standard for the under-fives, Health and Environment 1979;2(3):95-102.Growth monitoring started in the First NFNP (1977-1981) as a means to watch over and identify high-risk children at the earliest possible stage. The aggregate data obtained have been employed for national planning, for programme management and evaluation, and for early warning and intervention based on the concept of nutrition surveillance. At the beginning, children were weighed quarterly, almost entirely by health personnel, and the system did not become established until the early 1980s because the MOPH waited until 1982 before presenting the first nationwide report of cumulative results from January 1979 to March 1982. During the second NFNP (1982-1986), nationwide Primary Health Care offered the opportunity for widespread growth monitoring activities. The activities were carried out by the VHV/VHC and served as a tool for educating mothers about nutrition and for helping them determine the nutritional status of their own children.
Several evaluation studies at the begining of the third NFNP (1987-1991) indicated weaknesses at various steps of the growth monitoring process.78,79. Important weaknesses were: the incomplete census of children under five in most communities made it impossible to calculate the percentage of children the programme covered; VHV tended to focus on getting the weighing done quickly to shorten the mothers' waiting time thus seldom interpreted results to mothers or caretakers; and worst of all, mothers of children with moderate to severe malnutrition received no advice.
78. Teller CH. Community Nutrition Assessment and Evaluation: Towards Model Building. Thailand Trip Report Aug 15-29, 1987; International Nutrition unit Technical Report Series, U.S. Department of Health and Human Services, 1987.The Division of Nutrition have made several adjustments in response to these weaknesses. Since quarterly measurements are now being done by village health communicators and volunteers (VHC and VHV), the information on households with malnourished children is used on the spot to target them for more frequent follow-ups. In the weighing session, the VHV teaches the mother how to weigh the child and how to interpret the data. Individual level analysis of determinants of malnutrition is done for these second and third degree malnourished children who did not recover from malnutrition within the expected time of rehabilitation (Figure 3). The chart is supposed to be kept by the mother. Since 1988, these second and third degree malnourished children have also received food coupons from local MOPH officers for three months, if and when they come to the monthly weighings (5 Baht per child per day as compared with a minimum rural wage of 50 Baht per day). In 1990, the MOPH spent about 9,000,000 Baht per year (U$ 0.36 million) in coupons. Moreover, information from this GM is used for targetting high risk populations for intervention and for eventual visiting by provincial teams. At the central level, the Division of Nutrition, MOPH computerizes the aggregate data and disseminates the GM information to government agencies involved in food and nutrition activities.79. Suntikitruangruang C, et al. Strengthening growth monitoring/nutritional surveillance in PHC. Nutrition Division Research Report No. 1, 1987.
The most recent evaluation of the growth monitoring and promotion activities (GMP) in 199180 indicated that although mothers appreciated the chance to monitor their children's growth, there were limits to the degree of their enthusiasm. The poorest mothers, who can least afford to offer the opportunity cost of bringing their child to weighing sessions, are the ones most likely not to show up. About half (46%) of the mothers understood how to interpret nutritional status according to the colour on the chart and 62% knew about the directional changes on the chart (Table 39). There was also a major difference in attitudes between those responsible in the good and poor GMP villages. Generally, in good GMP villages considerable efforts were made to carry out the activities according to the guidelines whereas weighing might have been done only once a year in poor GMP villages. However, one of the most promising findings was mothers' wishes to be given more responsibility for weighing their children so that it could be done at their convenience rather than at a fixed time and place. The development and application of approaches, contents, messages, communication channels and materials which take into consideration the perceived needs, 'folk' wisdom and scientific knowledge are mandatory in the process of making growth monitoring more 'mother friendly' and 'action oriented'. Currently, under a UNICEF funded project to strengthen GMP, 400 randomly selected villages in 27 provinces (of 73) will start measuring lengths and heights of the under fives. The project will serve as a field trial to refine the protocol, management and supervisory functions for later nationwide implementation.
80. Evaluation of Growth Monitoring and Promotion in Thailand. An UNICEF Report. Nutrition Division, Ministry of Public Health. February 1992.In conclusion, growth monitoring in Thailand has been institutionalized from the national level down to the village level. However, there are still some concerns that deserve attention and corrective measures. Community-based growth monitoring has not yet covered most children as discussed earlier (section 7.2) and may have distorted the actual prevalence of malnutrition. The use of the Thai reference standard instead of the international reference (NCHS) also makes it difficult for international comparison. Furthermore, there seems to be a clear need for proper causal analysis by mothers and the community and improved communication with the target households and the communities in order for corrective and preventive measures to be fully implemented.
This activity has been carried out twice a year by teachers in all primary schools since 1986 (60-85% coverage in 1990). The indicator is weight-for-age using the Thai standard with 10th percentile cut-off. Malnourished and/or poor children are entitled to get exemption from payment for these lunches. The provincial primary education supervisor supposes to utilize these growth monitoring data for resource allocation for school lunch programmes. The data would also be passed to health personnel at the sub-district or the district level. The system has generally low visibility, and at central level, the data are used for targeting provinces which have more problems. However, the data from this nutrition surveillance system appears not to be regularly used to monitor changes in nutritional status nationwide.
81. NESDB. Strengthening Food and Nutrition Surveillance for Nutrition-Oriented Development Decisions: 1991 Progress Report. UNICEF, Thailand 1992.This rather new system (1989), actually called "Strengthening Food and Nutrition Surveillance for Nutrition-oriented Development Decision" is co-ordinated and spearheaded by the National Economic and Social Development Board (NESDB) supported by UNICEF. The FNSS was launched with the objective of pooling together and consolidating databases which existed in many government organizations at the provincial and district levels. The multi-sectoral, food and nutrition related information system would be utilized as an early warning system and a tool for planning, decision making and management at all levels.82. Winichagoon P and Schuftan C. Thailand: Food and Nutrition Surveillance System: An Inquiry into Output Data Utilization for Decision-Making. 9-15 December 1991.
It has just been expanded to an additional 16 provinces in 1991 after its pilot phase had been completed in only 4 provinces. So far, the FNSS information system has covered data on weather conditions (amount of rainfall, and soil fertility); agricultural production (crops, livestock and fishery); economic indicators (household income, wage rate); local consumer price index, health conditions (respiratory tract infections, acute diarrhoea and dengue haemorrhagic incidence) and nutritional status (birth weight, pre-school and school children). Recently, two additional indicators have been added: the non-agricultural income of the household and food consumption as reported by school children on recall to teachers from consumption the previous day. Also, all agricultural production is now translated into cash to allow for comparisons.
Since the beginning, the project has been continuously adjusted and restructured and, at the same time, rapidly expanded. Beginning in 1992, data aggregation for this surveillance system will be analyzed by the sub-district and district levels. Information obtained will be used to formulate the solution and development plans and feed primarily to the province for decision making and budgeting. Therefore, quarterly FNSS data will be used to identify priority areas needing more attention by each of the implementing agencies at provincial level. Communities will also request help from these agencies at provincial level for activities that they cannot undertake by themselves. Thus, the FNSS is considered as a means of involving province-level bureaucrats in using hard data for decision-making, and for the community (village committees and sub-district councils) to use the same data to prepare proposals for funding.
This experience may prove to be an innovative one. However, there are many theoretical and operational problems that need to be addressed and solved. For example, rainfall indicators should precede agriculture production indicators by at least 6 months. Cross-sectional analysis may be inappropriate in this case. Second, the existing data collection cycles (monthly, quarterly, annually) for each indicator are not the same. Third, analysis, interpretation, and criteria for decision-making at the district and provincial levels have not yet been so well established that the FNSS can be used effectively. However, the FNSS may be another mechanism that can empower local people to recognize their own problems and help them to formulate their own plans and mobilize their own resources. The results and experiences gained from this project are still quite preliminary and difficult to be evaluated and it may be too early to do so.
Supplementary Food Programmes
School Lunch Programme
Bangkok metropolitan
National Primary Education Authority
Area Based Programmes: The Nutrition Projects in Narathivas, Yala and Pattani
Supplementary feeding has been one component of nutrition activities. During the fourth NESDP, supplementary foods for infants and preschool children were centrally produced at the Institute of Food Research and Product Development (IFRPD), at Kasetsart University in Bangkok. Almost the whole budget was allocated through a request to the MOPH, based on their estimation of malnourished children. The food was distributed through the health infrastructure to the sub-district health centre to allow on-site feeding of malnourished children. There was a serious logistical problem in the distribution system: children who participated in the feeding often were not the malnourished ones.
During the fifth NESDP, the strategy changed to village-based supplementary food processing. The shift in strategy might be in part due to studies by the Institute of Nutrition, Mahidol University (INMU) where supplementary food formulas of rice, beans and groundnut or sesame were developed. Each formula of 100 g of the supplementary food provided approximately 450 Kcal and 12-14 g protein. These food mixtures could be processed in the village using simple, low-cost equipment and operated by trained villagers83. The mixtures were tested for acceptability and their impact in rural villages with favourable results84. The recipes were later modified and analyzed for nutrient composition, and the processing technique adopted by the MOPH for nationwide promotion of this supplementary food scheme.
83. Tontisirin K, Moaleekoonpairoj B, and Dhanamitta S, el al. Formulation of supplementary infant foods at the home and village level in Thailand. Food Nutr Bull 3(3):11-15, 1981.Supplementary food activities were generally inseparable from growth monitoring activities. When the second and third degree malnourished children were identified, the community shared the responsibility in assisting these children and their families. It was possible to provide supplementary food through village level by processing a mixture of rice and legumes for on-site feeding and take home, or food could be purchased from other villages. Supplementary food programmes were financed through the MOPH, started in the fifth NESDP, which introduced economic incentives by establishing village nutrition funds. Under this plan, MOPH provided target villages with a fixed amount of seed money for community efforts to improve nutrition. Development of village-based supplementary food processing allowed the communities to become self-reliant by taking action to alleviate their own nutrition problems. Although there was no nationwide assessment of the programme, various observations indicated that the food product was not well accepted in several rural communities. However, the strategy did serve to create both awareness of its importance and community concern and participation in solving the community's problems.84. Dhanamitta, S., Winichagoon, P. and Valyasevi, A., Promotion and distribution of supplementary foods at community level in Thailand, In: Health problems in Asia and in the Republic of Germany: How to solve them?, Schelp, F.P., ed., Vertag Peter Lang, 1985.
A new strategy of food coupons was then introduced in addition to the village food processing in 1988. The food coupon was given to individual children who were second and third degree malnourished. A monthly booklet of thirty coupons, each worth 3 baht in 1988 was given to the mothers of these children (5 baht in 1991). Every day, one coupon could be used at the local shop on specific items of food indicated on the coupon, such as eggs. Authorized shop owners in the village collected the coupons and were reimbursed from the sub-district health office. Since then combined second and third degree PEM has dropped from 2.3% in 1987 to less than 1% in 1991. How much of the improvement is attributable to this strategy remains unclear and debatable.
Educational attainment in Thailand slowly improved during the 1980s (Table 40). Although only 11-16% of the Thai have secondary and higher education, more than 70% have at least lower primary education and less than 10% are considered uneducated. National and government expenditure on education increased in real terms during the decade. Since the economy expanded rapidly at the end of the 1980s, the educational share of the GDP has slightly dropped as shown in Table 40, although it has still increased in real terms.
Primary education is compulsory. Public primary schools are responsible to two major agencies:
The office of education, the Bangkok metropolitan (BMA) is responsible for about 52% of school aged children in Bangkok. Most of these children are from lower socio-economic backgrounds. Therefore, this service is provided free of charge. The school lunch programme was started in these schools in 1977, and was claimed to have good coverage. Financial support for the programme is provided partially through governmental provision, and partially from donations from the private sector and individuals. The target group of the programme are children from poor families who cannot afford lunches. Out of 427 schools, 402 schools of varying sizes requested help for 40,879 children (as of 1991) and the budget per head per day was 1.85 baht (US$ 0.076).
The school lunch programme of the BMA was administered by the school committee. Teachers were responsible for the menu and preparation of the foods. Either simple and nutritious Thai single dishes (such as rice and Thai chicken curry, chicken noodle soup, etc.) or a snack at mid-morning or afternoon breaks (such as soybean milk, boiled mung beans with sugar added, etc.) were provided. The menu was planned with the nutritional content, and the use of low price protein sources, such as soy beans in mind.
Three offices in the BMA were responsible for the school lunch programme. The school service office assessed the problems and made the overall financial plan and budget allocation. The supervisory office was responsible for the training of teachers who would work on the programme, field supervision, and also provide the outreach programmes such as distributing soybean milk, promoting backyard gardens in schools, etc. The health office was responsible for the monitoring of school children and providing other health services, such as vaccination.
The school lunch programmes in primary schools in rural areas were organized through the national primary education authority. The planning division was responsible for planning and making proposals and the provincial primary education office was the implementation agency. 31,349 schools including 6.7 million school children were included in the plan (as of 1990).
For management, schools are divided into three categories:
- Schools in which students and their families can generally afford lunch without help. Usually, these schools are in towns and are big (in terms of the number of students). There is no need for financial assistance, and the setting is not appropriate for setting up agriculture and cooking activities.Provision of school lunches may differ from school to school. Manpower, financial availability, community support and most importantly, teacher's enthusiasm determine the extent of the programme. For example, some schools may provide school lunch every school day, whereas others may provide lunch every other day and/or soy milk during afternoon breaks as a supplementary food.- Schools in rural areas where agricultural production is readily feasible. These schools need some capital and running expenses to organize a school lunch. Activities can be organized by mobilizing students as a part of the curriculum. Lunches are sold to students at a low price, and most students can afford to buy lunches.
- Schools which are situated in rural poor communities where agricultural production is low or not feasible. Students are from poor families who cannot afford to buy lunch.
Support from the central level, including financial support is given to schools in the third category above - provision of educational materials; provision of agricultural implements for school gardens and cooking utensils; and training. Budget support from the government has been erratic and obviously inadequate. Guidelines in terms of management and technical expertise, have also been minimal and are greatly needed. On average in the 1980s, each student received only 10 baht (US$ 0.40) per year from the school lunch programme. It is interesting to note that the disparity between primary school students in Bangkok and in rural areas regarding the budget for the school lunch programme is quite conspicuous. Therefore, despite the fact that the school lunch programme is not new, its success has been rather modest. However, the Primary Education Authority is in the process of requesting a major increase in the budget of the school lunch programme from the government.
Nutrition programmes in the three provinces in the south of Thailand, where the majority of people are Muslim and Thai-Malay, have been under the patronage of the Crown Princess Mahachakri. The project was first launched in Narathivas in 1989.
The project initially followed the MOPH protocol. The financial assistance of the project, however, was from a special fund from the Crown Princess for nutrition activities. Growth monitoring had a coverage of 70% in 1988, increasing to 90% in 1989. Almost 1,800 children were identified as having second and third degree malnutrition. The nutrition coupon was the immediate measure which provided food assistance to the malnourished children. The improvement in the second and third degree malnutrition was satisfactory. However, it was realized that such protocol would not be sustainable in the long term.
In 1989, a workshop on the promotion of good nutrition for the Narathivas population was organized. Ignorance, poverty and cultural practices which differed from other ethnic groups were identified as the underlying causes of malnutrition. Aside from nutrition activities, most other complementary measures were confined to health activities, such as maternal and child care, immunization, etc.
Two principles were introduced for implementation. First, the problem solving principle. This strategy was used to identify and assess the magnitude of the problems. The holistic approach was devised, which involved setting the four major sectors to work together. Second, the preventive principle. Preventive measures were promoted with emphasis on community participation and self reliance. Personnel were hired for the project. They were expected to organize the training of village-based health volunteers.
In 1990, the project expanded to include other activities. From the agricultural sector, agricultural promotion included the introduction of appropriate technology, home economic training for women's groups, food production for consumption, animal husbandry and fishery activities. In addition, eleven child care centres were established in 4 districts by the coordinating efforts of the community development office. The budget for all the activities was partially provided from government allocation, and partially from the Crown Princess.
