Is growth monitoring worthwhile? An evaluation of its use in three child health programmes in Zaire

Growth monitoring has become a major component of many child health programmes in developing countries over the past two decades. Little research has been carried out on the separate contribution of growth monitoring to the effectiveness of child health programmes, and discussion on the subject frequently take on an exhortative rather than a scientific character. This paper reports some of the results of an evaluation of three child health programmes in rural Zaire which used growth monitoring as a screening tool for targeting health and nutrition interventions. The monthly sessions to which mothers brought their children were observed, the health workers interviewed, and information obtained on the supervision system in the programmes, in order to determine wether the health workers accurately identified at-risk children and provided appropriate interventions through the use of growth monitoring information. Health staff were observed weighing and consulting a total of 506 mothers and children. Whilst they measured and recorded weights accurately, they did not carry out any further investigation in one-third of children who had experienced growth faltering. Similarly, no counselling was given to one-third of mothers whose children were ill and/or had growth faltering, called collectively 'at-risk children'. Generally, the quality of advice and referral for illness was more satisfactory than the nutritional advice given to mothers, which consisted of brief, standard directives. The value of individual screening by weighing is questioned, since attendance was infrequent and non-representative, many mothers identified their children as ill and therefore at-risk even before they were weighed, and since nearly two-thirds of children attending the sessions were classified as at-risk. The theoretical gain in health service efficiency by targeting was largely lost by the staff-time required to weigh and record the weights of individual children, and the fact that the information that a child had growth faltering was frequently not acted upon. The programmes did not exploit the potential of growth monitoring as an educational and motivational tool to promote action by mothers and communities to improve their children's health. The use of growth monitoring did not appear to be an important factor in the overall quality of care within these three programmes. The disappointing results of this evaluation, which have been mirrored in other recent reports, and a review of the theoretical grounds for growth monitoring, have led the authors to conclude that the case for including growth monitoring in child health programmes remains unproven either on theoretical grounds or in practice. There is a critical need for further research into the cost-effectiveness of growth monitoring, but the introduction of growth monitoring into future child health programmes appears difficult to justify at present.