In light of the significant effects of ill health and malnutrition on educational outcomes, the role of effective health promotion and simple school-based programs to deliver low-cost interventions becomes increasingly important (Bundy and others 1992). Other chapters provide information on the integrated management of childhood illness, early child development, and adolescent health (see chapters 63, 27, and 59, respectively). The focus here is on ill health and malnutrition at school age and the role of the formal and nonformal education sector in delivering interventions.
Developing a Programmatic Approach
The focus of school health and nutrition programs in low-income countries has shifted significantly over the past two decades away from a medical approach that favored elite schools in urban centers and toward an approach that improves health and nutrition for all children, particularly the poor and disadvantaged. This change began in the 1980s, when research showed not only that school health and nutrition programs were important contributors to health outcomes but also that they were essential elements of efforts to improve education access and completion, particularly for the poor.
In an effort to reconceptualize the relationship between health and education, the United Nations Education, Scientific, and Cultural Organization (UNESCO) hosted a series of workshops on this topic in the 1980s (Bundy 1989; Halloran, Bundy, and Pollitt 1989) and supported one of the first authoritative reviews of the area (Pollitt 1990). Similarly, the United Nations Development Programme, in conjunction with the Rockefeller, Edna McConnell Clark, and J. S. McDonnell Foundations supported the creation of the Partnership for Child Development to strengthen the evidence base across the education and health sectors and to support the dissemination of information (Berkley and Jamison 1990; Bundy and Guyatt 1996). This paradigm shift coincided with the World Conference on Education for All in Jomtien, Thailand, in 1990 and led to renewed efforts by countries and agencies to develop more effective programmatic approaches to school health and nutrition.
The United Nations Population Fund (UNFPA) has pioneered population and family life education (PopEd) as an intrinsic part of school curricula. In 1994, the International Conference on Population and Development placed specific emphasis on school health, including reproductive and sexual health. Efforts at country level have addressed PopEd both within the school system and outside, and the concept has evolved to include references to family life education, sex education, HIV/AIDS awareness and prevention, and life-skills programs. Today, approximately 84 countries have UNFPA-supported school health programs.
In 1995, the World Health Organization (WHO) launched its Global School Health Initiative to foster the development of health-promoting schools (HPSs) (WHO 1996). The concept started in Europe in the early 1990s, based on the Ottawa Charter of Health Promotion (WHO 1986), which recognized that health is created by caring for oneself and others, by being able to make decisions and have control over one's life and circumstances, and by creating conditions that support health for all. WHO's European Regional Office, the Council of Europe, and the Commission of the European Communities widely promoted the concept of HPSs to foster healthy lifestyles and develop environments conducive to health (European Commission, WHO Europe, and Council of Europe 1996). Although definitions vary among regions, countries, and schools, an HPS may be characterized as one that is constantly strengthening its capacity as a healthy setting for living, learning, and working. The initiative fosters the development of HPSs by the following:
consolidating research and expert opinion to describe the nature and effectiveness of school health programs
building capacity to advocate for the creation of HPSs and to apply the components to priority health issues
strengthening collaboration and national capacities to assess the prevalence of important health-related behaviors and conditions and to plan and implement policies and programs that improve health through schools
creating networks and alliances, including regional networks.
The key elements of how this approach is interpreted today are listed in table 58.1.
In the mid 1990s, the United Nations Children's Fund (UNICEF) began promoting the Child-Friendly Schools framework as a holistic way to promote children's rights as expressed in the Convention on the Rights of the Child (UNICEF 1990) and children's access to education as stated in the World Declaration of Education for All (UNESCO 1990). This approach included a gender-sensitive component, which was further strengthened when girls' education became the first priority in UNICEF's Medium Term Strategic Plan, 2002-5. Another key element is skills-based health education, including life skills, which has been promoted through UNICEF with partner organizations as part of HPSs, child-friendly schools, and the framework for Focusing Resources on Effective School Health (FRESH). Research shows that this approach is more effective than traditional strategies, which tend to be didactic and to focus on scientific information alone. In contrast, skills-based health education uses the experiences of students as the starting point and explores the links between knowledge, attitudes, and the interpersonal skills required to promote health and learning (UNICEF, WHO, World Bank, UNFPA, UNESCO 2003). The approach is interactive, activity based, and flexible so that it can be used to address a range of health and social issues, including HIV/AIDS, sanitation, drug use, violence and bullying, nutrition, and cross-cutting issues such as gender and culture. Some key elements of how the child-friendly schools approach is interpreted currently, including its focus on healthy and protective learning environments, are listed in table 58.1.
Also during the 1990s, the World Bank Human Development Network sought to support countries in implementing school health and nutrition programs (Del Rosso and Marek 1996; World Bank 1993) and launched an International School Health Initiative with the aim of raising awareness among decision makers in the education sector.
Thus, the 1990s were characterized by the creation of a number of apparently separate programs to promote and support school health. However, analysis at the country level revealed that although the various agency initiatives used different "prisms" to view school health—public health for WHO, quality education for UNESCO, and child rights for UNICEF—the core activities for all the programmatic approaches were essentially the same.
A major step forward in international coordination and cohesion was achieved when the FRESH framework was launched at the World Education Forum in Dakar in April 2000 (World Bank FRESH Toolkit 2000). Among the early partners in this effort were the Education Development Centre, Education International, the Partnership for Child Development, UNESCO, UNICEF, the World Food Programme (WFP), WHO, and the World Bank. This partnership recognizes that the goal of universal education cannot be achieved while the health needs of children and adolescents remain unmet and that a core group of cost-effective activities can and must be implemented across the board to meet those needs and to deliver on the promise of EFA.
The expanded commentary on the Dakar Framework for Action reflects the recommendations of this partnership and describes three ways in which health relates to EFA: as an input and condition necessary for learning, as an outcome of effective quality education, and as a sector that must collaborate with education to achieve the goal of EFA. In the follow-up to the Dakar Forum, UNESCO designated FRESH as an interagency flagship program that will receive international support as a strategy to achieve EFA.
The FRESH framework, which is based on good practice recognized by all the partners, provides a consensus approach for the effective implementation of health and nutrition services within school health programs. The framework proposes four core components that should be considered in designing an effective school health and nutrition program and suggests that the program will be most equitable and cost-effective if all of these components are made available, together, in all schools:
Policy: health- and nutrition-related school policies that are nondiscriminatory, protective, inclusive, and gender sensitive and that promote the nutrition and physical and psychosocial health of staff, teachers, and children
School environment: access to safe water and provision of separate sanitation facilities for girls, boys, and teachers
Education: skills-based education, including life skills, that addresses health, nutrition, HIV/AIDS prevention, and hygiene issues and that promotes positive behaviors
Services: simple, safe, and familiar health and nutrition services that can be delivered cost-effectively in schools (such as deworming services, micronutrient supplements, and nutritious snacks that counter hunger) and increased access to youth-friendly clinics.
The FRESH framework further proposes that these four core components can be implemented effectively only if they are supported by strategic partnerships between the following groups:
health and education sectors, especially teachers and health workers
schools and the community
children and others responsible for implementation.
Adopting this framework does not imply that these core components and strategies are the only important elements; rather, implementing all of these in all schools would provide a sound initial basis for any pro-poor school health program.
The common focus has encouraged concerted action by the participating agencies. It has also provided a common platform on which countries, agencies, donors, and civil society can support all programs, including agency-specific programs (table 58.1). Another important consequence of the FRESH consensus framework has been to offer a common point of entry for new efforts to improve health in schools, as illustrated by the three examples in box 58.1.
This consensus approach has increased significantly the number of countries implementing school health reforms. The simplicity of the approach, combined with the enhanced resources available from donor coordination, has helped ensure that these programs can go to scale. Annual external support from the World Bank for these actions approaches US$90 million, targeting some 100 million schoolchildren.
Table 58.2 lists some specific interventions commonly combined within the school health intervention package, but it should be recognized that not all of these interventions will be needed or be appropriate for all locations. Some interventions are synergistic: for example, worm infection will be addressed by the provision of latrines, the promotion of hand washing, relevant health and hygiene education, and deworming services. Similarly, HIV/AIDS infection among youths will be addressed by ensuring girls' participation in school, offering skills-based health education (including life skills), offering peer education, providing access to health clubs, and providing access to treatment for sexually transmitted infections (STIs) at clinics. It is also apparent that whereas some interventions promote multiple outcomes—for example, skills-based health education and life-skills development can help promote positive behaviors that prevent STIs and substance abuse—other interventions may have a single focus, such as iron supplementation to avoid anemia.
More than 100 million school-age children are out of school; 60 percent are girls (UNESCO 1993). School health programs in Guinea and Madagascar have demonstrated that many of these children will take advantage of simple services, such as deworming, provided in schools (Del Rosso and Marek 1996); the school acts essentially as a community center. It also has been demonstrated that deworming programs in schools benefit out-of-school children by reducing disease transmission in the community as a whole (Bundy and others 1990).
Nevertheless, it is apparent that out-of-school children cannot benefit from many of the important components of school-based programs, such as skills-based health education and life-skills development programs to prevent HIV/AIDS. Reaching these children requires more flexible approaches that combine the best of nonformal, informal, and community-based approaches (see chapter 59).