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Foreword

Ensuring that children are healthy and able to learn is as essential component of an effective education system. Good health and nutrition at school age are especially relevant to efforts to achieve universal education, since Education For All strategies aim to bring more girls and more of the poorest and most disadvantaged children to school. These children are often the least healthy and most malnourished and have the most to gain educationally from improved health and nutrition.

School health and nutrition programs provide one of the most cost-effective ways to promote the education, health, and nutrition of school children, particularly if they are developed as part of community partnerships and delivered by the education sector. Such programs have an additional importance today because they provide one of the most important ways to reach adolescents and the broader community with messages about HIV/AIDS prevention.

School-based health and nutrition programs are not a new concept, but historically such programs have often been inefficient and retrogressive, usually favoring the better-off children in urban centers. A new efficient and progressive approach to school health has now been developed by a partnership of agencies, including UNESCO, WHO, UNICEF, WFP, and the World Bank. This framework for action seeks to Focus Resources on Effective School Health through the FRESH concerted action program.

The School Health Toolkit is designed to assist in the development of school health and nutrition components for World Bank projects, based on the policies and programs that have been defined by the FRESH interagency initiative. This ensures that client countries can develop programs which capture the best practices from program experiences and which follow a framework for action which has been adopted by all major stakeholders.

Because of the focused and collaborative nature of the FRESH approach, there has been a significant increase in the number of countries able to implement school health components within Bank Projects. FRESH was launched at the World Education Forum in Dakar, Senegal, in April 2000. There are now more than 20 World Bank education, nutrition, or health projects in Africa which include a FRESH component.

I hope that this School Health Toolkit will provide World Bank clients and staff with the information they need to prepare effective School Health and Nutrition programs wherever in the world there are poor schoolchildren who can benefit from them.

Ruth Kagia, Director Christopher Lovelace, Director Robert Holzmann Education Health, Nutrition, and Population Social Protection

February 2002 The FRESH Framework Focusing Resources on Effective School Health, Hygiene, and Nutrition Programs

A Toolkit for Task Managers

What is the Aim of the Toolkit?

To assist the preparation of quality School Health and Nutrition programs as components of World Bank Projects

Who Asked for this Toolkit to be Developed?

Clients and task teams of the World Bank who are preparing school health and nutrition programs for the first time.

How Does the Toolkit Help Ensure the Quality of School Health Programs?

The toolkit is based on the interagency FRESH framework of best practice in school health and nutrition. FRESH is the acronym for Focusing Resources on Effective School Health.

Why Does the FRESH Framework Assure Quality?

A consortium of agencies, including UNESCO, UNICEF, WHO, and the World Bank, launched FRESH at the World Education Forum in Dakar, Senegal, in April 2000. FRESH describes a cost effective framework for school health and nutrition programs, based on the best practices identified by these agencies.

How Does the Toolkit Assist Project Preparation?

The toolkit contains specific examples of school health and nutrition components of World Bank Education; Health , Nutrition, and Population (HNP); and Early Child Development (ECD) projects, and of the documentation required at each stage in World Bank project cycle.

What Specific Examples of World Bank Documents Does the Toolkit Include?

The toolkit includes material from Project Concept Documents (PCD), Terms of Reference (TOR) for consultants, Project Appraisal Documents (PAD), LogFrames (logical frameworks for decision making), and Letters of Understanding (LOU).

February 2002 Section 1. What is the Purpose of this Toolkit?

 This toolkit is designed to assist Bank task managers and their clients during each of the steps required to prepare the school health and nutrition components of a school health project.

 The toolkit provides illustrations of the school health components for education; health, nutrition, population (HNP); and early childhood development (ECD) projects.

 These examples, which come from actual Bank-funded projects, may be used when preparing documents or providing technical assistance to countries.

 The toolkit was developed in response to specific requests from task managers and includes material for preparing project concept documents (PCDs), terms of reference (TORs), project appraisal documents (PADs), logical frameworks (logframes) and letters of understanding (LOUs).

February 2002 Section 2. Project Concept Document: Why School Health and Nutrition Programs in Bank Projects? A Rationale for including FRESH in Social Sector Programs

Backed by the experiences of a wide variety of school health programs, the FRESH partnership was launched at the World Education Forum in April 2000, with the support and developmental assistance of WHO, UNICEF, UNESCO, and the World Bank. The FRESH framework is the basic approach currently used by the Bank and other agencies for developing school health programs.

Effective educational systems must ensure that children are healthy and able to learn. Good health increases enrollment, reduces absenteeism, and brings the poorest and most disadvantaged children to school. These children—many of whom are girls—are often the least healthy and most malnourished. They often have the most to gain educationally from better health.

Effective school health programs developed as part of community partnerships provide among the most cost-effective ways for reaching school-age children, adolescents, and the broader community. Also important—they offer a sustainable means for promoting healthy practices. School health is a major investment in a country’s future and in the capacity of its people to thrive economically and socially. School-based programs like FRESH that deliver effective health, hygiene, and nutrition services offer children and communities a wide variety of benefits, including:

Responding to an expanding need

School-age children have benefited from the success of child survival programs and the significant growth of government and community efforts to expand basic education coverage: Statistics show that more school-age children and a greater proportion of these children are attending school. Almost 90% of the world’s children survive beyond their fifth birthday, and about 80% of these are enrolled in school. In many countries, targeted education programs have ensured that many of these new entrants are girls for whom good health is especially important.

Increasing the efficacy of other investments in child development

School health programs are the essential sequel and complement to early childcare and development programs. Continuing good health at school age is essential for children to sustain the advantages of a healthy early childhood and to take full advantage of what may be their only opportunity for formal learning.

Ensuring improved educational outcomes

Although school children around the world have a lower mortality rate than infants, their exposure to the illnesses associated with socialization can adversely affect their development. It is estimated that the burden of disease for school children from 5 to 14 years old is 11% of the total global burden of disease. Micronutrient deficiencies, common parasitic infections, poor vision and hearing, and disability may have a detrimental effect on school enrollment and attendance as well as on cognition and educational achievement. In older children, avoidance of risky behaviors may reduce the dropout rate due, for example, to early pregnancy. Ensuring good health at school age may boost school enrollment and attendance, reduce the need for repetition, and increase educational attainment, while good health practices can promote reproductive health and help avoid HIV/AIDS.

February 2002 Achieving greater social equity

As a result of universal basic education strategies, some of the most disadvantaged children—girls, the rural poor, and children with disabilities—have gained access to school for the first time. But poor health compromises this group’s ability to attend school and to learn. Health interventions will benefit these children the most, because betterment of health status will be most likely to improve their attendance records and learning achievements.

Providing a highly cost-effective strategy

School health programs help link the health, education, nutrition, and sanitation resources in an infrastructure—the school—that is already in place, is pervasive, and is sustained. While the school system is rarely universal, coverage is often superior to health systems and has an extensive skilled workforce that already works closely with the community.

The FRESH framework is the starting point for developing a cost-effective school health, hygiene, and nutrition program in a more child-friendly and health-promoting school. The aim is to focus on interventions that are feasible to implement even in the most resource-poor schools. The core framework has four components that should be made available in all schools:

 Health-promoting school policies that, for example, do not exclude pregnant girls; encourage healthy, tobacco-free lifestyles; help to maintain the education system in the face of HIV/AIDS and ensure that the education sector has clear and transparent policies on issues relevant to HIV/AIDS.

 Safe water and sanitation provision to support a healthy learning environment, reinforce hygiene messages, and offer privacy and promote participation in adolescent girls’ education.

 Skills-based approach to health, hygiene, and nutrition education that supports development of knowledge, attitudes, values, and life skills for establishing enduring health practices and reducing youth and teachers’ vulnerability to HIV/AIDS, as well as for promoting healthy and hygienic behaviors and good nutrition.

 School-based health and nutrition services that are simple, safe, and familiar and that address problems that are prevalent and recognized as important within the community, such as school-based counseling to cope with the HIV/AIDS epidemic, deworming, and micronutrient supplements.

To be implemented effectively, these activities must be supported by intersectoral partnerships between health and education; partnerships with the community (PTAs) and with the children themselves; and efforts linked to monitoring and evaluation resources.

Food delivery and physical examinations are two critical components that are often proposed or included in school health and nutrition programs. These components should be carefully examined before they are considered appropriate for inclusion in Bank-supported projects:

 Physical examination by health personnel is generally not cost-effective in schools and often inequitable since the exams may reach only children in urban secondary schools attended by the more affluent children. Physical examination is rarely linked to referral.

February 2002  If the food is to reach the poor and to avoid the potentially significant political and opportunity costs of delivery by the education sector itself, food for school children is often best delivered through community programs instead of in schools.

References

The FRESH Partnership is more fully described in World Bank, 2001, “Focusing Resources on Effective School Health: A FRESH Start to Enhancing the Quality and Equity of Education,” Washington, D.C.

The Rationale is given in more detail in the following documents:

I. Core Intervention 1: Health Related School Policies II. Core Intervention 2: Provision of Safe Water and Sanitation III. Core Intervention 3: Skills Based Health Education IV. Core Intervention 4: Access to Health and Nutrition Services. V. Cost of School Health and Nutrition Interventions

February 2002 I. Core Intervention 1: Health-related School Policies

The FRESH framework, an intersectoral partnership to Focus Resources on Effective School Health, provides the context for effective health-related school policies. School policies, promoting good health and a non-discriminatory, safe, and secure physical and psychosocial environment, are most effective when supported by other reinforcing strategies, such as the provision of safe water and sanitation, skills-based health education, provision of health and other services, effective referral to external health service providers, and links with the community. The FRESH framework provides this context by positioning health-related school policies among its four core components, which should be made available jointly for all schools: I. Health-related school policies II. Safe water and sanitation III. Skills-based health education IV. Access to health and nutrition services These core components of the FRESH framework require school-community partnerships to be the supporting strategies for successful school health and nutrition programs. These strategies include effective partnerships between the health and education sectors, teachers and health workers, schools and community groups, and between the pupils and those responsible for implementing school health programs.

Ensuring that children are healthy and able to learn is an essential component of an effective education system. This is especially necessary for achieving education for all in the most deprived areas. Good health increases enrollment, reduces absenteeism, and brings more of the poorest and most disadvantaged children to school. Many of these new, disadvantaged students are girls. These girls and boys are often the least healthy and most malnourished, have the most to gain from improved health, and need health-related school policies that, when effectively endorsed, can lead to better educational outcomes.

1. Why Health-related School Policies?

Health policies in schools, including skills-based health education and the provision of some health services, can help promote the overall health, hygiene, and nutrition of children. But good school health policies should go further to ensure a safe and secure physical environment and a positive psychosocial environment. Such policies should address issues of abuse of students, sexual harassment, health-related practices of teachers and students, school violence, bullying, and guaranteeing the further education of pregnant schoolgirls and young mothers; all of these activities are designed to help promote inclusion and equity in the school environment.

Policies that help to prevent and reduce harassment by other students and even by teachers also help prevent girls from withdrawing or being withdrawn from schools. Policies regarding the health-related practices of teachers and students can reinforce health education: teachers can act as positive role models for their students, for example, by not smoking in school. The process of developing and agreeing upon policies draws attention to these issues. The policies are best developed by involving many levels, including the national level, regional and district level, and the school level—including the teachers, children, parents, and the wider community.

February 2002 2. Why School Health Policies Are Necessary for Effective School Health and Nutrition Programs

 School health policies can provide highly visible opportunities to demonstrate commitment to equity, non-discrimination, gender issues, and human rights as well as serving as a positive model for the whole society.

 Policies are necessary for and can give a clear structure to a safe, protective, and inclusive school environment.

 Policies, when clearly communicated to the school population and the whole society, can provide rules on how to behave and what is accepted or not accepted in the school setting.

 Policies that are actively accepted and endorsed by the PTA and the community can be followed more effectively. In cases when policies are not followed, there will be a demand for change and stricter monitoring will be possible.

School health and nutrition policies must be developed and supported by key stakeholders at all levels. At the national level, for example, this involves an accepted framework of responsibility, policies, and action among the key government ministries (such as Health and Education Ministries) and other institutions and organizations with an input and responsibility for school health programming. At district and school levels, policies should be clearly understood, implemented, and supported by all those responsible for the education, health, and well being of the children. Policies should cover a broad spectrum of areas critical for the health and development of school-age children. Examples given here include policies relating to early pregnancy and exclusion from school; tobacco and tobacco free schools; sanitation in the school environment; HIV and reproductive health education; sexual harassment and abuse of students; the role that teachers can play in delivering simple health services through schools; and the public-private partnerships for delivery of school food services.

To be effective, school policies need resources for their implementation. This means that adequate resources must be made available at the national, regional, district, and local levels. Such resources include government financing, but may also include contributions from other donors, such as NGOs, and ultimately, to ensure long-term sustainability of effective implementation of school health and nutrition policies, support from parents and the local community.

3. Content of School Health Policies

Strong intersectoral cooperation is required to plan, implement, and monitor a sustainable school health program. It should be clearly defined and inscribed in a common statement, describing who is responsible for the interventions planned and who will be implementing those interventions. This cooperation and communication strategy should be recorded in a “protocol d’accord” or “memorandum of understanding” between the education and health sectors.

The Ministry of Health (MoH) is responsible for the health of school-age children, but this age group is rarely a priority for the health sector. Delivery of health services to children under 5 and pregnant women—the typical priority groups for the MoH—frequently leaves few resources left for the schoolchildren. The education of schoolchildren is the priority of the Ministry of Education and if “improved learning and education achievement by improving health and nutrition” is the adopted approach, then it also becomes the ministries’ priority to assure the

February 2002 health of the school-aged child. Thus, the protocol d’accord needs to make transparent the tasks to be shared between the two ministries. This is the first step towards a successful school health program.

MAURITANIA Memorandum of understanding between Ministry of Education (MEN) and Ministry of Health (MSAS)

Foreword: The Quality Education for all programs in MEN has a School Health (SH) component with the objective of improving learning by improving pupils’ health and nutrition. In this setting, the MEN and MSAS have agreed: Article 1: Form a National Technical Committee in school health regrouping all the services from the two departments that are active in the domain Article 2: Creation of a national coordination with MEN for the SH program Article 3: The MEN give the necessary funds (via contract) to MSAS (CAMEC) for availability of medicine and micronutrients (disbursement, quality control, transportation, storage…) Article 4: Establish a tight collaboration between the two departments whatever the hierarchy level: central and peripheral Article 5: The MEN is responsible for all the activities in the school environment: 1) Planning the activities in school:  Implement  Sustain  Evaluate  Supervise 2) Mobilization of the necessary resources (human and financial) 3) Coordination of all the activities in school 4) Management of the financial activities in relation to SH 5) Curriculum revision and elaboration of guidelines, manuals, modules, pedagogical and didactic support 6) Teacher training of professional teaching staff (teachers, inspectors, directors), PTAs, and NGOs in the domain 7) The professional teaching staff is responsible for the distribution of medicine and micronutrients in the schools under the supervision of health personnel (doctors, nurses…) Article 6: The MSAS is responsible for: 1) Curative aspects:  Therapeutic protocol (dose and frequency of treatment)  Availability of medicines (disbursement, quality control, storage, transport, delivery) 2) School Health aspects:  The scientific content of health education adopted for schools  Training of teachers in the issues of school health  Technical supervision of PTA and NGO’s operating in the domain  Participating in the elaboration of the manuals, guidelines, modules, and pedagogical and didactic support

4. Examples of Policies

February 2002 Unwanted early pregnancy and exclusion from schooling

Adolescents1—children 10 to 19 years old—are not physiologically mature enough for childbearing; early childbearing is associated with high levels of maternal mortality and morbidity, low birth weight, and higher risk of infant mortality. In addition, there are many socioeconomic benefits to delaying early childbearing with better opportunities for improved education, avoidance of repetition, reduction of dropout rates, and an increased chance to acquire skills and knowledge for her and her family’s future life.

As access to education has increased and the benefits of postponing childbearing have become more widely known, unwanted pregnancies have declined in most countries. The use of contraceptives and demand for access to contraception has increased in equal measure, particularly among unmarried women in many parts of the world. Still, the proportion of unsafe abortions with extreme health risks remains high. Survey data indicate that the proportion of young mothers with unwanted pregnancies varies widely within and between regions. In Sub- Saharan Africa, about 11 to 13% of pregnancies are unwanted in Niger and Nigeria, compared to 50% or more in Botswana, Ghana, Kenya, Namibia, and Zimbabwe.

Female children are underrepresented in primary level enrollment. Globally, 46% of enrolled children are females with more differences to be found in the poorest countries. Some two-thirds of females are not enrolled in secondary school and those that are enrolled often drop out. The reasons for drop out are many including the involvement in waged labor, the high direct and opportunity cost of schooling, gender-biased curriculum and teaching practices, including discrimination of girls, and premature fertility. Young women with low levels of educational and economic attainment often experience restricted ability and motivation to regulate their fertility, resulting in higher rates of early pregnancy. The cycle is further perpetuated as young women who are in school are forced to discontinue their education when they become pregnant, thereby greatly restricting their economic opportunities.

In Jamaica, adolescent pregnancy has long been a serious concern. In 1977, the proportion of births to teenage mothers rose to 31% of all births, often following a pattern of three to four children before the age of 20. Since 1977, the Women’s Center of Jamaica Foundation has started a quality program with the objective of motivating young mothers to choose education instead of continuous motherhood. They have since helped over 22,000 mothers return to the school system. Figures for 1997 show that the program reached 51 % of the 3,016 mothers under 16 who gave birth in the country. The achievements include:  A decrease in negative societal attitudes displayed towards the teen mother;  The breakdown of the barriers within the ministry of education and changes in the education code to allow teenage mothers to return to the school system;  A decline in the teen pregnancy rate from 31% in 1977 to 23% in 1997. Other important outcomes are that all children to mothers in the intervention group are in school and that no pregnancies have occurred in the adolescent children of women who participated. There is a need to prevent unwanted early pregnancies through policies in schools that include family life education and family planning in secondary school curricula Reduction of risk behaviors through a skills-based health education is the most effective approach. Young women with higher levels of education are more likely to postpone marriage and childbearing. Fertility

1 The term “adolescent” refers to people between the ages of 10-19, according to a 1998 joint statement by WHO, UNICEF and UN Population Fund.

February 2002 levels among the least educated and the most educated women in Peru differ by five children. In Guatemala, adolescent birth rates are higher among those with no schooling. Adolescents who postpone childbirth are five times more likely to finish their secondary education.

Case studies from Guinea and Côte d’Ivoire show that for a girl, an unplanned pregnancy could mean shame for the family, an end to her education, and rejection by the baby’s father. Often she is blamed by her friends and discriminated against.

To improve girls’ educational outcomes and fight exclusion and discrimination it is essential to institute health-related policies, supported by the community, PTA, and schoolchildren that will ensure that a pregnant girl can stay in school and continue her education.

Policy:

 Do not exclude pregnant girls from school.  Encourage students to return to school after childbirth.  Include family life education in the curriculum.  Prohibit all kinds of gender-based discrimination.

Tobacco and the tobacco free school

Tobacco use is one of the chief preventable causes of death in the world. The adverse health effects of tobacco use among smokers are well known. Tobacco use generally begins during adolescence and continues through adulthood, sustained by addiction to nicotine. Recent trends indicate an earlier age of initiation and rising smoking prevalence rates among children and adolescents. If these trends continue, tobacco use will result in the deaths of 250 million of the people who are children and adolescents today.

In recent years, many health agencies have called for concerted action against tobacco use among young people and for more data and information on tobacco use among schoolchildren. To supply the data, 12 countries conducted the Global Youth Tobacco Survey project in 1999 to provide more information on tobacco use among schoolchildren and to enhance the capacity of countries to design and implement their own tobacco control and prevention programs. The survey showed that between 10 and 33% of 13 to15-year-old children smoked—a percentage that was found to be higher among boys than girls. One-fifth or more of young people begin smoking before the age of 10. There is a higher risk of being addicted or becoming heavy smokers when smoking begins at such a young age. The survey also showed that laws restricting the sale of tobacco to young people are seldom enforced.

February 2002 Evaluation studies of 10 US school-based prevention programs have shown sustained reductions in tobacco and alcohol use. Evaluation of life-skills training targeting 4,466 seventh graders showed 50 to 70% reductions in tobacco and alcohol use with significant impact after three years. The Star program similarly reduced tobacco, alcohol, and marihuana use by 30% in 4,978 sixth and seventh graders. This study concluded that prevention in schools is most effective when school lessons are reinforced by a clear, consistent social message that teen alcohol, tobacco, and drug use is harmful, unacceptable, and illegal. It is very important to involve families and communities, as many of these curricula do.

The vast majority of children exposed to environmental tobacco smoke (ETS) do not choose to be exposed. Given that more than one billion (one US thousand million) adults smoke worldwide, WHO estimates that around 700 million, or almost one-half of the world’s children, breathe air polluted by tobacco smoke.

The substantial number of exposed children and the evidence that environmental ETS causes illness in children constitutes a substantial public health threat. Governments have a responsibility to legislate to control exposure to tobacco smoke in public spaces such as schools. Educational strategies, including effective education on health risks to children, are likely to be more effective when culturally specific public policy is in place. The overall goal is to protect this vulnerable group from exposure and support and help them to avoid starting unhealthy smoking habits and addiction.

Policy:

 No smoking in schools by teachers and students.  No selling of cigarettes to children.  No tobacco advertising and promotion.  Higher tobacco prices and no possibility of purchasing cigarettes individually.

Sanitation, gender, and privacy, as well as maintenance of facilities by the community

Lack of facilities and poor hygiene affect both girls and boys, although poor sanitation conditions at schools have a stronger negative impact on girls. All girls should have access to safe, clean, separate, and private sanitation facilities in their schools. If there are no latrines and hand-washing facilities at school, or if they are in bad repair, many children would rather not attend school than use the alternatives. It is particularly important that girls who are old enough to menstruate have adequate facilities at school that are separate from those of boys. If their facilities are not separate, they may miss school monthly, finding it difficult to catch up and ultimately being more likely to drop out of school altogether.

A national sanitation policy and an implementation strategy should be developed in collaboration with all key stakeholders. Local collaboration is required to develop commitment and support maintenance of the facilities in schools by the community.

February 2002 “Lack of latrines, especially separate latrines for girls, was identified as the worst school experience for girls. This draws attention to the special conditions and experiences that prevent girls from fuller participation and achievement. Privacy issues relating to sanitation are major factors forcing girls out of school” (Dr Crispus Kiyonga, Minister of Health, Uganda).

In January 1997, an action plan was created to raise the profile of sanitation in Uganda. A concept paper was written and published using existing data including socioeconomic, environmental, and educational effects; the number of girl dropouts and data on lack of privacy; and health and nutritional effects. A working group with four specific subgroups was appointed: Legislation, Policy, Planning, and Organization of a national forum with members from each district. Also drafted were:  An environmental health policy  An environmental health act  Two national sanitation plans.

Lessons learned from a DPHE-UNICEF study in 1994 and 1998 in Bangladesh were that provision of water and sanitation facilities in schools increased girl’s attendance by 15%. Interaction with family and demand for sanitation facilities at home were seen in 80% of children where those practices were acquired at school.

Policy:

 Separate latrines for teachers, boys, and girls.  Safe water in all schools.  Active commitment from PTA for maintenance of water and sanitation facilities.

HIV and exclusion, the content of sex education, and access to condoms

HIV infection is one of the major problems facing school-age children today. They face fear if they are ignorant, discrimination if they or a family member or friend is infected, and suffering and death if they are not able to protect themselves from this preventable disease. It is estimated that 40 million people worldwide are living with HIV or have AIDS; at least one-third of these are young people aged 15 to 24. In 1998, more than 3 million young people worldwide became infected including 590,000 children under 15. More than 8,500 children and young people become infected with HIV each day. In many countries, over 50% of all infections are among 15 to 24-year-olds, who are likely to develop AIDS in a period ranging from several months to more than 10 years. In Sub-Saharan Africa, teenage girls frequently become infected.

Studies have shown the enormous impact that HIV and AIDS have on the education sector and the quality of education provided, particularly in certain regions of the world such as Sub-Saharan Africa. Consequences of the AIDS epidemic include a probable decrease in the demand for education, coupled with absenteeism and an increase in the number of orphans and school dropouts, especially among girls. Girls are socially and economically more vulnerable to

February 2002 conditions that force people to accept risk of HIV infection in order to survive. A decrease in education for girls will have serious negative effects on progress made over the past decade toward providing an adequate education for girls and women. Reduced numbers of classes or schools, a shortage of teachers and other personnel, and shrinking resources for educational systems all impair the prospects for education.

Effective, skills-based, HIV/STD/reproductive health education and prevention is needed in all schools for all children so that no one is left ignorant. Yet in many places, schools are apprehensive about providing sex education or discussions of sexuality because of cultural demands to protect adolescents from sexual experience. Women often lack skills needed to communicate their concerns with their sexual partners and to practice behaviors that reduce their risk of infection, such as condom use, which is often controlled by men.

The school can either be a place that practices discrimination and prejudice and creates undue fear or one that demonstrates society’s commitment to equity. School policies need to ensure that every child and adolescent has the right to skills-based life education, particularly when that education is necessary for survival and the avoidance of HIV infection.

A UNAIDS review (1997) of 53 studies that assessed the effectiveness of programs to prevent HIV infection and related health problems among young people concluded that sex education programs do not lead to earlier or increased sexual activity among young people; in fact, the opposite seems to be true. In the review, 22 studies reported that HIV and/or sexual health education delayed the onset of sexual activity, reduced the number of sexual partners, or reduced unplanned pregnancies and STD rates. In addition, 27 studies reported that HIV/AIDS and sexual health neither increased nor decreased sexual activity, pregnancy, or STD. The review concluded that school-based interventions are an effective way to reduce risk behaviors associated with HIV/AIDS/STD among children and adolescents.

A WHO review of studies on sexuality education found that access to counseling and contraceptive services did not encourage earlier or increased sexual activity. In Europe and Canada where comprehensive sexuality education and confidential access to condoms are more common, the rates of adolescent sexual intercourse are no higher than in the United States and teenage pregnancy rate is lower.

In South Africa until late in 1999, the Department of Education had no policy on HIV/AIDS. In August 1999, the Department’s Corporate Plan 2000-2004 identified action on HIV/AIDS as one of the five priorities. The main objectives: (i) raising awareness about HIV/AIDS among educators and learners; (ii) integrating HIV/AIDS into the curriculum; and (iii) developing models for analyzing the impact of HIV/AIDS on the system.

February 2002 Education’s HIV/AIDS policy is consistent with the priorities of the Department of Health’s strategic plan, but goes further to provide guidance on discrimination in schools and institution. It specifies that: The constitutional rights of learners and educators must be protected equally There should be no compulsory disclosure of HIV/AIDS status No HIV-positive learner or educator may be discriminated against Learners must receive education about HIV/AIDS and abstinence in the context of life-skills education as part of the integrated curriculum Educational institutions will ensure that learners acquire age and context-appropriate knowledge and skills to enable them to behave in ways that will protect them from infection Educators need more knowledge of and skills to deal with HIV/AIDS and should be trained to give guidance on HIV/AIDS Source: Carol Coombe CICE, December 2000, Managing the impact of HIV/AIDS on education in South Africa.

Policy:  Skills-based health education focusing on HIV/AIDS prevention.  Stimulate peer support and HIV/AIDS counseling in schools.  No discrimination of HIV-positive teachers or students.  Access to condoms.

Sexual harassment and abuse of students including by teachers

Sexual abuse and violence are serious problems that transcend racial, economic, social, and regional lines. Violence is frequently directed at females and youth who lack the economic and social status to resist. Adolescents and young women in particular may experience abuse in the form of domestic violence, rape, and sexual assault and sexual exploitation. Accurately estimating the prevalence of sexual abuse and violence in the developing world is difficult due to the limited amount of research done on the subject and the fact that cultural acceptance prevents reporting.

Violence against women is a widespread problem in Sub-Saharan Africa. Surveys conducted reveal that 46% of Uganda women, 60% of Tanzania women, 42% of Kenyan women, and 40% of Zambian women report regular physical abuse. Studies have shown that children who witness violence, particularly within an abusive household, may experience many of the same emotional and behavioral problems that physically abused children experience such as depression, aggression, physical health complaints, and poor school performance.

Worldwide, 40 to 47% of sexual assaults are perpetrated against girls age 15 or younger, most often by a male relative, neighbors, or a male teacher. Young girls frequently report that their early sexual experience were coerced often due to lack of economic power or the need to be approved to pass from one grade to the next in school. Young women are vulnerable to coercion into sexual relationship with older men—”sugar daddies”—who take advantage of their lack of economic resources and promise to help pay for expenses, such as school fees in exchange for sex. In South Africa, 30% of girls reported that the first sexual encounters were forced and in

February 2002 rural Malawi, 55% of adolescent girls surveyed reported that they were often forced to have sex. In Kenya, 50% of adolescent girls admit receiving gifts when engaged in sex and in Uganda 22% of primary school children anticipate receiving a gift or money in exchange for sex.

An effective school system requires clear policies and strict laws that ensure children a safe and secure school environment without sexual assault and harassment by teachers and older classmates. The policies must be well known and accepted by everyone, including schoolchildren and effectively enforced by the community and PTA.

Policies may be in place in many countries, but the threat of social stigma often prevents young women from speaking out about rape and abuse and the laws are commonly not enforced.

All Anglophone countries in Africa have enacted laws that directly address sexual offences against minors. The age at which young people are protected by rape laws varies in these countries from under 13 years in Nigeria to under 16 years in Zimbabwe.

Workshops (one for teachers and one for pupils) were the final stage of the research on “The Abuse of girls in Zimbabwean Junior Secondary Schools.” The workshop gave the following recommendations for strategic actions:  Breaking the silence is the key to addressing the issue at all levels—among girls, teachers, school heads, parents, and Ministry officials. Open dialogue; begin information sharing and cooperation.  Girls can support each other and act as a group, refuse to see a teacher alone, move around the school, and walk home together with other girls. Report cases, as a group. Make clear to the teachers that they are aware of the code of conduct of teacher behavior and that misconduct is a punishable offence.  Teachers can create a friendlier and more supportive environment, avoid verbal abuse, and act as positive role models for both boys and girls at all times. Teachers can also take the school’s Guidance and Counseling lessons more seriously, make them more participatory, encourage girls to speak about difficult issues, and use drama, drawings, and writing to include everyone.  School management can change the school culture of violence by enforcing effective disciplinary measures against teachers and pupils who indulge in abusive behavior. Provide a forum for pupils especially girls to talk about issues of abuse in a non- threatening environment, possibly with individuals outside the school. Teach pupils greater self-esteem and establish an effective pupil representation system (student council). School management can ensure that only qualified, trained teachers teach Guidance and Counseling. Ensure that teachers know that they will be reported if they transgress the regulations and that all rules regarding pupil behavior are enforced. Ensure that parents understand the school regulations and become involved in the formulation of school policy on teacher and pupil management. Work closely with parents and the community.  The Ministry of Education can ensure a rigorous selection of trainee teachers and head teachers and provide a gender awareness component in all in-service training courses and workshops. Source: Fiona Leach and others, Department for International Development, Education Research, Serial no 39, 2000.

February 2002 Policy:  Ensure by law that sexual harassment and violence in the school environment by teachers and pupils is prohibited.  Make the law well known and accepted by everyone, empower adolescents to report cases, and enforce effective disciplinary measures for those who abuse.

Role of teachers in delivering a simple health package through schools

Schools can effectively deliver health and nutritional services provided that the services are simple, safe, and familiar and address problems that are prevalent and recognized as important within the community.

School health policies that allow teachers to deliver a simple health package (including anthelmintics and micronutrient supplements) have been shown to be effective, inexpensive, and acceptable to teachers and parents. The impact of these school-based control programs show tremendous promise for reducing morbidity and increasing learning of school-age children (WHO 1999). Teachers need to be trained well to monitor and deal with any side effects of treatment, in cooperation with local health workers.

Large-scale, school-based health and nutrition programs in Ghana, Tanzania, India, and Indonesia (50,000 to 3 million children) have shown that with training and supervision teachers can administer anthelmintic drugs (albendazole for intestinal nematodes and praziquantel for schistosomiasis) and micronutrient supplements to children at school. Teachers and the community perceived this as an acceptable role for teachers (Partnership for Child Development 1997).

Policy:  Training and use of teachers to deliver simple health interventions in collaboration with health sector workers and with involvement of the local community.

Food vendors—nutrition and hygiene

Policy development and setting the objectives of school nutrition provides the framework for implementation of all the other recommendations aimed at improving education through better health and nutrition. Analyzing the health and nutrition situation of schoolchildren with a focus on causes of energy and micronutrient deficiencies has become a method of engaging governments in the problems of that age group and alerting them to the necessary content of the policy for school nutrition programming and provision of school food services.

Many governments have given private enterprises the responsibility for preparing and delivering a ready-to-eat meal or snack. Some say that governments should encourage small local enterprises. Some school canteens in Lesotho, for example, are run by former local vendors who successfully bid on the privatized service, while in Nigeria, state and local governments train and license vendors to sell to schoolchildren. In Indonesia, school principals use their power to choose the vendors who serve their schools.

Other problems to tackle through policies are the quality and hygiene of the food served in the schools. Governments need to regulate products sold by commercial vendors as well as the

February 2002 standards of sanitation. Even in the United States, concern for the nutritional quality of foods provided by private vendors has made the move to privatization slow; yet where it has occurred, the benefits appear to be substantial.

The author discusses the significant contribution that street food trade makes to the diet of school-age children in some areas and argues for using this part of the food distribution system when considering school nutrition programming. Project experiences suggest that the informal institution of street food vendors has been used effectively to deliver nutrition/food assistance to schoolchildren. Working with street vendors to improve the nutritional quality and safety of these foods involves an approach that considers not only the needs of children but also the financial viability of the enterprise and the training and management needs of the individual vendor. It is suggested that the success of using this approach for school nutrition programming depends on involving all institutions that may affect the legitimacy of this economic activity, i.e., municipal and local government, ministries of education, and health and nongovernmental organizations that represent vendors’ interests (M. Cohen, 1991, “Use of microenterprises in the delivery of food programs to school children,” Washington, DC: World Bank).

Converting from a government-supplied to a privately supplied school lunch program in Rhode Island has lead to less expensive yet tastier and more nutritious lunches in the public schools there. The state government recently terminated its 25-year-old program of centrally planned and purchased lunches for the public schools and hired private contractors to take over the program. The annual cost of the program plummeted from US$11 million to US$200,000 and federal and state subsidies fell almost one-half. An expressed concern at the time of the conversion was that privately run programs would emphasize profit over nutritional quality, but the new program delivers higher nutritional value than the old program did and student participation in the program has soared (Stephen Glass, September 3, 1995, “Incredible yet Edible; How Rhode Island Beefed up its School Lunch Program, Washington Post.)

Policy:  Regulation of vendors and the quality, hygiene, and standard of the food provided.

5. The Way Forward

The Convention of the Rights of the Child, now ratified by most countries of the world, gives governments the political responsibility to endorse and monitor clear health-related policies. School health policies can provide highly visible opportunities for the governments and the whole society to demonstrate a commitment to equity, non-discrimination, gender issues, and human rights in all of the schools in their countries. School policies should be clearly communicated to the school population and actively monitored by the PTA and the community. In the new FRESH framework, one of the four core interventions is school policy providing a safe, inclusive, and non-discriminatory environment. These policies are most effective when supported by other reinforcing strategies such as the provision of safe water and sanitation, skills- based health education, and the provision of basic health and other services. When implemented jointly, these four interventions will lead to better learning outcomes and improved health of the school-aged child in the 21st century.

February 2002 References

Advocates for Youth. 1997. “The Impact on Early Pregnancy and Childbearing on Adolescent Mothers and their Children in Latin America and the Caribbean.” AFY fact sheet.

———. 1998. “Adolescent sexual and reproductive health in Sub-Saharan Africa.” AFY fact sheet.

———. 1998b. “School Condom Availability, 1998.” AFY fact sheet.

———. 1998c. “Sexual Abuse and Violence in Sub-Saharan Africa.” AFY fact sheet. (Available at http://www.advocatesforyouth.org.)

Bundy, D.A.P. and H. L. Guyatt. 1996. “Schools for Health: Focus on Health, Education and the School-age Child.” Parasitology Today 12: 1-16.

Coombe, Carol (CICE). 2000. “Managing the Impact of HIV/AIDS on Education in South Africa.” December.

Cohen, M. 1991. “Use of Microenterprises in the Delivery of Food Programs to School Children.” Washington DC: World Bank.

Glass, Stephen. 1995. “Incredible Yet Edible; How Rhode Island Beefed Up its School Lunch Program.” Washington Post. (September 3).

Leach, Fiona and others. 2000. Department for International Development, Education Research, Serial no 39, 2000.

Measure Communication, Population Reference Bureau. 2000. “The World’s Youth 2000 Data Sheet.” Available at (http://www.measurecommunication.org)

Senderowitz, J. 2000. “A Review of Program Approaches to Adolescent Reproductive Health.” Poptech Assignment Number 2000. 176.

UNICEF/IRC. 2000. “Global Workshop on School Sanitation and Hygiene Education.” Workshop Report, March.

Warren, C.W. and others. 2000. “Theme Papers. Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project.”

WHO. 1996. “Improving School Health Programmes: Barriers and Strategies.”

———. 1999. “Preventing HIV/AIDS/STI and Related Discrimination: An Important Responsibility of Health Promoting Schools.” Information Series on School Health, Document Six.”

———. 1999a. “International Consultation on Environmental Tobacco, Smoke and Child health.” Tobacco Free Initiative.

———. 1999b. “Monitoring Helminth Control Programs. A guide for Managers of Control Programs.”

February 2002 ———. 1999c. “Tobacco Use Prevention: An Important Entry Point for the Development of Health Promoting Schools.” Information Series on School Health, Document Five.

———. 1999c. “Violence Prevention: An Important Element of a Health Promoting School. Information series on School Health,” Document Three.

———. 2000. “Local Action Creating Health-Promoting Schools.” Information Series on School Health.

February 2002 II. Core Intervention 2: Provision of Safe Water and Sanitation

The FRESH framework, an intersectoral partnership to Focus Resources on Effective School Health, provides the context for provision of safe water and sanitation facilities for children in schools. Policies to create a healthy school environment by providing safe water and sanitation facilities within schools and improving children’s health, well-being, and dignity are likely to be most effective where they are supported by other reinforcing strategies. These strategies include policies to provide a non-discriminatory, safe, and secure environment, skills-based health education, provision of health and other services, effective referral to external health service providers, and links with the community. The FRESH framework provides this context by positioning the provision of safe water and sanitation among the four core components that should be made available jointly for all schools. The core components are: I. Health-related school policies II. Safe water and sanitation III. Skills-based health education IV. Access to health and nutrition services These core components of the FRESH framework require school-community partnerships to be the supporting strategies for the success of school health and nutrition programs. They include effective partnerships among the health and education sectors, teachers and health workers, schools and community groups, and between the pupils and those responsible for implementing school health programs.

Despite all the progress reported worldwide in recent decades, more than 2.3 billion people still live without access to sanitation2 facilities and are unable to practice such basic hygiene as washing their hands with soap and water. Diseases related to poor sanitation and water availability cause many people to become ill or even to die. Children are the most vulnerable to health hazards and consequently are the most affected. In 1998, there were 2.2 million deaths due to diarrhea diseases, of which the vast majority were children. In addition, poor sanitation has led to the infection of nearly one billion people—largely children—with a variety of worm infections, with corresponding costs in health and energy.

While the impact of poor sanitation and hygiene is known to be disastrous for infants and young children, it also has a major impact on the health of school-age children including adolescents. It is obvious that lack of sanitation and hygiene is a public disaster that deserves the highest priority.

Most of these infections, which are related to poor sanitation and hygiene, are preventable. Diseases such as diarrhea and parasitic worm infections need to be tackled by making improvements to water and sanitation facilities. Such improvements must go hand in hand, however, with hygiene behavior change, if they are to prevent the transmission of disease.

Disease is not the only problem caused by poor sanitation in the school environment. Providing safe and separate sanitation facilities for girls, particularly adolescents, is one of the key factors in promoting greater school attendance by girls and preventing them from staying away from school, particularly during menstruation.

21 Improved environmental sanitation and hygiene behavior involves change. The term sanitation, therefore, is defined as a process whereby people demand, effect and sustain a hygienic and healthy environment for themselves, their family members and their community.

February 2002 Access to sanitation facilities is a fundamental right that safeguards health and human dignity. Providing those facilities at school not only helps to meet that right, it also provides the most favorable setting to encourage behavior change in the school and in the community.

Implementing the right to sanitation is critical to positive outcomes in early childhood care, for young children and adolescents, especially girls.

How sanitary can conditions be when 90 young children in a school are sharing one toilet? Or when 54% of the toilets are not functioning? Primary schools in some of the poorest countries have inadequate sanitation facilities, according to a pilot survey of 14 countries in 1995. The average number of users is often higher than 50 students per toilet in city schools. None of the 14 countries had increased the number of school toilets by more than 8% since 1990, suggesting that they are barely managing to keep pace with the rise in student populations. Somewhat better progress had been achieved in providing safe water in schools. Inadequate sanitation and water in schools jeopardize not only students’ health but also their attendance. Girls in particular are likely to be kept out of school if there are no sanitation facilities. Source: UNICEF, Progress of Nations 1997, p. 13.

1. Why School Hygiene and Sanitation: The Health Perspective

Roundworm, whipworm, hookworm, schistosomiasis, and other flukes and/or guinea worm infect about 400 million school-age children, often multiple infections occurring simultaneously. These parasites consume nutrients from children they infect. In so doing they bring about or aggravate malnutrition and retard children’s physical development. This can lead to stunting,3 underweight, and anemia (iron deficiency anemia (IDA)).

Recent studies strongly suggest that school-age children suffer from higher levels of stunting than previously acknowledged. Stunting is increasingly used as an indicator of population well-being and poverty. Estimates from the WHO global database are that 53% of school-age children in developing countries are suffering from IDA. When levels of anemia exceed 40%, it is considered a public health problem requiring the provision of iron supplements, a health service included in the FRESH framework along with deworming.

3 Stunting and underweight refers to <-2z.scores of the NCHS reference median for height for age and weight for age.

February 2002 Morbidity and mortality associated with various water and sanitation-related diseases Disease Type Morbidity (no. of Mortality (deaths Population at Risk cases each year) each year) Diarrhea <4,000 million 2.5 million <2,000 million Amoebic dysentery 48,000 70,000 <2,000 million Cholera 145,000 (1996 data) 10,000 (1996 data) <2,000 million Roundworm 250 million 60,000 <2,000 million Hookworm 151 million 65,000 <2,000 million Whipworm 43.5 million 10,000 n/a Guinea worm 70,000 None 100 million Trachoma 600 million (6 None 500 million million blind) Schistosomiasis 200,000 20,000 600 million Source: World Health Report 1998.

Helminth, particularly hookworm infection, has been shown to cause iron deficiency anemia (IDA), reduce growth and may negatively affect cognition (Stoltzfus et al 1997). An estimated 210 million schoolchildren suffer from IDA (Del Rosso and Marek 1996). There is substantial evidence that IDA in children is associated with decreased physical and mental development and impaired immune function. Inadequate water and sanitation facilities can contribute to high rates of transmission of helminth infections, which, in turn, contribute to iron deficiency anemia.

Figure 1 shows that the highest rates of roundworm and whipworm infections are often demonstrated in groups of 5 to 9 and 10 to 14 year olds.

Figure 1. Worm infection by age (adapted from Bundy 1988)

100

80

d e t c e f 60 n i

e g a t

n 40 e c r e P 20 Ascaris Trichuris Hookworm

0 0 10 20 30 40 50 60 Age (years)

February 2002 Global prevalence and number of cases of intestinal helminth infection in school-age children are estimated at: Roundworm 35% (320 million), Whipworm 25% (233 million), Hookworm 26% (239 million) (Partnership for Child Development 1997).

Because most of the worm infections are preventable, the emphasis should be on key interventions to interrupt the transmission of these diseases:

 The safe, efficient, and hygienic disposal of feces, particularly child feces.

 The safe, efficient, and hygienic management of water from extraction, through transport and storage to use (particularly for drinking and hand washing).

 The regular and effective use of water (with a scouring agent like soap or ash) for hand washing after contact with stools (Curtis 1998).

Multiple, coordinated strategies produce a greater effect than individual strategies, but these strategies need to be selective and targeted. While treatment of parasitic infections may have an immediate short-term impact, a program will only show a sustainable effect when combined with training of teachers and administrators, classroom education, and the provision of sanitary facilities—all included in the FRESH framework of action.

2. Why School Hygiene and Sanitation: The Learning Perspective

As numerous studies show, education and health are inseparable: stunting, nutritional deficiencies, diarrhea, and helminth infections affect school participation and learning.

It is well known that stunted children enroll late into school and probably are less likely to complete their schooling with long-term consequences for educational performance, outcome, and productivity. Importantly, many of these issues can be addressed effectively through health, hygiene, and nutrition policies and programs for students and staff.

Helminth reduction programs in schools can have a significant impact on health and learning among schoolchildren. Deworming of school-age children can improve both growth and educational achievement, especially for the children most heavily infected.

Data from studies show that the prevalence of stunting increased with age indicating a higher proportion of stunted school-age children (Partnership for Child Development 1998). Studies have shown that linear growth continues beyond the normal puberty growth period. This suggests that school-based programs aimed at improving health and nutrition status may have the potential to bring about catch-up growth in stunted school-age children (Stoltzfus et al 1997 1998).

Children with heavy worm burdens are likely to be absent from school for a greater proportion of the time than those who are lightly infected or free from worms (Figure 2).

February 2002 Figure 2. School absenteeism and helminth infection

0.3 t n e s b a

0.2 r a e y

f o

n 0.1 o i t r o p o r P 0 Uninfected Low Moderate High 0 1-<2000 2000-<7000 >7000 Whipworm Intensity (epg)

Nokes & Bundy 1993

Although limited in number, studies show that learning outcomes of healthy children are better than those for children infected with helminths (Figure 3).

Figure 3. Improvement in cognitive performance with treatment for whipworm infection in school children in Jamaica

Verbal Fluency

25

24 Treatment

23 e Uninfected r o

c 22 S Placebo 21

20

Pre-intervention 3 mths Post-intervention

Nokes et al 1992

There is also a positive association between education and productivity, meaning that infections that inhibit educational achievement are likely also to affect production during adulthood.

3. Why School Hygiene and Sanitation: The Gender Perspective

Lack of facilities and poor hygiene affects both girls and boys, although poor sanitation conditions at schools have a stronger negative impact on girls. All girls should have access to safe, clean, separate, and private sanitation facilities in their schools. If there are no latrines and

February 2002 hand-washing facilities at school or if they are in a poor state of repair, many children prefer not to attend rather than use the alternatives. In particular, girls who are old enough to menstruate need to have adequate facilities at school and normally separate from those of boys; this point is strongly supported by FRESH. Without these facilities, the girls may miss school that week and find it hard to catch up, making them more likely to drop out of school altogether.

Many children, again mainly girls, miss out on time at school because they are have to walk long distances to fetch water; when the schoolteacher sends children to fetch water, it is predominantly girls who are sent.

Lessons learned from a DPHE-UNICEF study in 1994 and 1998 in Bangladesh showed that provision of water and sanitation facilities in schools increased girls’ attendance by 15%. Interaction with family and demand for sanitation facilities at home were seen in 80% of children where those practices were acquired at school. In addition to the obvious health benefits and time savings (particularly affecting young school-age girls), provision of safe water and sanitation facilities can also have an influence on school enrollment and attendance. The lack of adequate, separate sanitary facilities in schools is one of the main factors preventing girls from attending school, particularly when menstruating. In Bangladesh, a school sanitation program increased girls’ enrolment by 11%, a level that is beyond the reach of conventional educational reform (Cairncross 1998).

When other family members become sick (often due to sanitation-related diseases), girls are more likely to be kept home to help. This can lead to reduced school attendance by girls and can result in an increase in dropout rates. This situation will become even more critical in communities hard hit by the HIV/AIDS pandemic.

4. Why School Hygiene and Sanitation: The Child’s Perspective

Children spend long hours in schools. The school environment will partly determine the children’s health and well-being by providing a healthy or unhealthy environment. Compared to adults, children are often more receptive to new ideas and can more easily change their behavior and/or develop new long-term behaviors because of increased knowledge and facilitated practices.

Depending on the culture, children and youth may question existing practices in the household and become agents of change within their families and communities. Teachers as professionals and influential individuals, supported by the school management, can play an important role in the development of pupils through training and providing a role model in the communities.

Life skills training (LST) as promoted by FRESH and used in water and sanitation education can help children make informed decisions and avoid risky situations and behaviors and give them opportunity to practice these skills. They are more effective than traditional teaching methods in influencing behavior rather than just imparting knowledge. These skills are best acquired through learner-centered, participatory, experimental programs (e.g., WHO 1996).

February 2002 Children are future role models and parents. What they learn at school is likely to be passed on to their peers and to their own children. It is obvious that all sanitation facilities and educational programs should be adapted to the physical and cultural needs of girls and boys at different ages, key aspects enshrined in the concept of child-friendly schools.

5. School Sanitation Facilities Are Not Enough

Although there is an urgent need for speeding up the installment of appropriate facilities, school sanitation deals with more than building child-friendly facilities. Experience shows clearly that the mere provision of services, be it within schools or at household level, will not be sustainable. Facilities need to be maintained and in order to be maintained there must be a recognized need and demand for water as well as sanitation at schools. To improve the sanitation environment of schools and to ensure benefits from safe and clean facilities, behavioral change is needed, leading to a proper use of the facilities as well as organized maintenance of the facilities and sanitation-related behaviors such as hand-washing.

Government officials from six different countries in Sub-Saharan Africa gave situation reports on water and sanitation at home and in schools at the Water and Sanitation workshop in October 2000 in Burkina Faso. For most of the countries, the assessments showed lower coverage in schools of water and latrines compared to the general population and low state of usage and maintenance. In Côte d’Ivoire, for example, 62% in rural areas had water and 40 % in the capital Abidjan had sanitation. In schools, only 30% has water and 32 % latrines. According to a survey in the Yopougon area, Côte d’Ivoire, 62% of WCs do not work and there are about one WC/latrine per 381 students (suggested 1/40 girls and 1/80 boys) and one urinoire per 892 students (suggested 1/50).

Schools are an integral part of a community. Involvement of the local community in school sanitation and hygiene activities increases the effectiveness of the programs. It also promotes the sense of ownership within communities that is needed to sustain the school systems for operation and maintenance, particularly important in the absence of effective local government to provide such services. Although school sanitation and hygiene promotion can bring health benefits for the children and their family members who may improve their sanitation, it is clear that sanitation is a public good and that sanitation improvement has much greater benefit when it is achieved by a whole community. Experience shows that children can act as potential agents of change within their homes and communities through their knowledge and use of sanitation and hygiene practice learned at school.

A recent review of 144 different interventions demonstrated the impact on morbidity of general water, sanitation, and hygienic interventions:  36% median reduction of diarrhea from the safe disposal of feces;  35% median reduction of diarrhea from hand-washing with soap after contact with stools;  20% median reduction in diarrhea from protection of water from fecal contamination;  26% median reduction in diarrhea from the integration of hygiene education or promotion in water projects (Esrey et al 1990).

February 2002 However, without mobilization and motivation of the community as a whole, the impact of a school sanitation and hygiene promotion program may remain limited.

6. Targets for the Future

The shared world vision for hygiene sanitation and water supply, based on the recognition of hygienic conditions and adequate access to safe water and sanitation services as fundamental rights, includes school sanitation and hygiene education targets. The suggested school sanitation and hygiene education targets for 2015 are:

 80% of primary school children educated about hygiene; and  All schools equipped with facilities for sanitation and hand washing.

These targets are most effectively implemented within the context of the FRESH Partnership, for which provision of safe water and sanitation for schools is positioned as one of the core FRESH activities.

References

Bundy, D.A.P. 1988. “Population ecology of intestinal helminth infections in human communities.” Philosophical Transactions of the Royal Society, London (B). 331: 405-420.

Cairncross, S. 1998. “Why promote sanitation and hygiene?” UNICEF workshop on environmental sanitation. Unpublished.

Cairncross, S. and others. 1998. “The public and domestic domains in the transmission of disease.” Tropical Medicine and International Health 1: 27-34.

Curtis, V. 1998. Hygienic, healthy and happy: A manual for setting up hygiene promotion programmes. New York: UNICEF.

Del Rosso. J.M. and T. Marek. 1996. Class Action. Improving School Performance in the Developing World through Better Health and Nutrition. Washington, DC: World Bank.

Esrey, S. and others. 1990. “Health benefits from improvements in water supply and sanitation: survey and analysis of the literature on selected diseases” (WASH technical report no. 66).

Hubley, J. 1998. “School health promotion in developing countries.”

Nokes, C., S.M. Grantham-McGregor and A.W. Sawyer. 1992. “Moderate to heavy infections of Trichuris trichiura affect cognitive function in Jamaican schoolchildren.” Parasitology 104: 539-547.

Nokes, C. and D.A.P. Bundy. 1993. “Compliance and absenteeism in schoolchildren: implications for helminth control.” Transactions of the Royal Society of Tropical Medicine and Hygiene 87: 148-152.

February 2002 Partnership for Child Development. 1997. “This wormy world: Fifty years on.” Parasitology Today November 1997 (poster).

———. 1998. “The anthropometric status of schoolchildren in five countries in the Partnership for Child Development.” Proceedings of the Nutrition Society 57: 149-158.

———. 2000. “What’s new in the health and nutrition of the school-age child and in school health and nutrition programmes?” Paper prepared for ACC/SCN meeting April 2000.

Stoltzfus, R.J. and others. 1997a. “Linear growth retardation in Zanzibari school children.” Journal of Nutrition 127, 1099-1105.

———. 1997b. “School based deworming programmes yields small improvement in growth of Zanzibar school children after one year.” Journal of Nutrition 127: 2187-2193.

———. 1998. “Effects of the Zanzibar school based deworming program on iron status of children.” American journal of Clinical Nutrition 68: 179-186.

WHO. 1996. “Strengthening Interventions to Reduce Helminth Infections: An Entry Point for the Development of Health-Promoting Schools.” WHO/HPR/HEP/96.10.

———. 1996. Information Fact Sheet No. 112, November 1996.

Workshop Report. 2000. UNICEF/IRC Global Workshop on SSHE. Delft, 11-18 March 2000.

February 2002 III. Core Intervention 3: Skills-Based Health Education

The FRESH framework, an intersectoral partnership to Focus Resources on Effective School Health, provides the context for effective implementation of skills-based health education programs. When delivered through schools, skills-based health education is most effective when it is supported by other reinforcing strategies, such as policies to provide a non-discriminatory, safe, and secure environment, safe water and sanitation, health and other services, effective referral to external health service providers, and links with the community. The FRESH framework provides this context by positioning skills-based health education among the four core components that should be made available together for all schools: I. Health-related school policies II. Safe water and sanitation III. Skills-based health education IV. Access to health and nutrition services. These core components of the FRESH framework require school-community partnerships to be the supporting strategies for the success of school health and nutrition programs. They include effective partnerships between the health and education sectors, teachers and health workers, schools and community groups, and between the pupils and those responsible for implementing school health programs.

The challenges facing children growing up in the 21st century, especially those challenging the poorest and most disadvantaged children living in low-income countries, are greater than ever. Millions of children are affected by problems of poor nutrition, infectious diseases, inadequate access to clean water and sanitation, violence, substance abuse, and the increasing threat and burden of living with HIV/AIDS. Children and young people need to be equipped with the knowledge, attitudes, values, and skills that will help them face these challenges and assist them in making healthy life-style choices as they grow. One of the best approaches is skills-based health education, delivered through schools. Through this method, children can be helped to face these challenges and make healthy choices.

1. Why Skills-based Health Education?

There is widespread growth in the application of skills-based health education, particularly life skills, to areas such as HIV/AIDS prevention, reproductive health, early pregnancy, violence, tobacco, and substance abuse. In these areas, individual behavior, social and peer pressure, cultural norms, and abusive relationships may all contribute to the health and lifestyle problems of children and adolescents. There is now increasing evidence that, a skills- based approach to health education works and is more effective than teaching knowledge alone.

Numerous studies indicate that it is necessary but not sufficient to provide information about issues such as sex, STDs, and HIV (transmission, risk factors, how to avoid infection) necessary and to lead to healthy behavioral change (Hubley 2000). Programs that provide accurate information to counteract the myths and misinformation frequently report improvements in knowledge and attitudes, but this correlates poorly with behavioral change related to risk- taking and desirable behavioral outcomes (Gatawa 1995; UNAIDS 1997a). Skills-based health education can be effective in the more difficult task of achieving and sustaining behavior change.

February 2002 Skills-based health education is widely applicable

Although the areas outlined above are viewed as problems largely affecting older children and adolescents, both this age group and younger children also face a wider range of health, hygiene, and nutrition problems where skills-based health education can play a vital role in sustainable prevention and management. Examples of this include water and sanitation-related diseases such as helminth4 infections.

Globally, millions of children are infected with parasitic helminths, with the greatest burden in the poorest countries (an estimated 320 million with roundworm, 233 million with whipworm and 239 million with hookworm (PCD 1997)). School-age children are the most heavily infected group in terms of both prevalence and intensity of infection. Helminth infections are estimated to account for over 12% of the total disease burden in girls aged 5 to 14 years and over 11% of the burden in boys, making this the single largest contributor to the disease burden of this group. Helminth infections have been shown to cause iron deficiency anemia (particularly hookworm), reduce growth, and (possibly) negatively affect cognition (Drake et al 2000; Stoltzfus et al 1998).

Skills-based health and hygiene education programs play a vital role in combating diseases such as helminth infections. They accomplish this through promoting Knowledge of areas such as symptoms, transmission, and behaviors that are specifically relevant to helminth infection in each community; Attitudes such as responsibility for personal, family, and community health; Confidence to change unhealthy habits; Skills such as avoiding behaviors that are likely to cause infection; Encouragement to others to change unhealthy habits; and Communication of messages about worm infection to families, peers, and members of the community (WHO 1996).

Skills-based health education can also be seen as widely applicable to a range of other areas where knowledge, attitudes, and skills play a critical role as part of a comprehensive strategy for combating disease and promoting healthy life styles. This includes a wide range of diseases and conditions that affect the health of children and adolescents, including: vector-borne diseases such as malaria; water and sanitation-related diseases such as diarrheal diseases, trachoma, and schistosomiasis; nutrition-related conditions such as micronutrient deficiencies and other forms of malnutrition.

The skills-based approach extends traditional methods of teaching about health, which tend to be knowledge-based and didactic in approach. In contrast, skills-based health education focuses upon the development of Knowledge, Attitudes, Values, and Skills (including life skills such as interpersonal skills, critical and creative thinking, decision making, and self awareness) needed to make and act on the most appropriate and positive health-related decisions. Health in this context extends beyond physical health to include psychosocial and environmental health issues. This approach utilizes student-centered and participatory methodologies, giving participants the opportunity to explore and acquire health-promoting knowledge, attitudes, and values and to practice the skills needed to avoid risky and unhealthy situations and to adopt and sustain healthier life styles.

4 Helminth infections include soil-borne intestinal nematodes such as roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura) and hookworm and water-borne species such as Schistosoma haematobium and S. mansoni.

February 2002 HIV/AIDS—A critical need for skills-based health education

For HIV/AIDS, the scale and impact of the problem is so great that the urgency of implementing preventative measures, including skills-based health education, is critical. Skills- based health education programs are being increasingly adopted as means to reach children and young people to help halt the spread of this crippling epidemic. Studies from African countries show that children between the ages of 5 and 14 have the lowest prevalence of HIV infection. Children below age 5 are susceptible to mother-to-child transmission; after they become sexually active, the rate of infection increases rapidly—especially for girls (Kelly 2000). Children aged 5 to 14 need to be reached at this critical stage in their lives to open the “window of hope” that stops the spread of HIV/AIDS.

2. Skills-Based Health Education Does Change Behavior

There is now strong evidence from an increasing number of studies that skills-based health education, applied in an appropriate context, changes behavior—including behavior in sensitive and difficult areas in which knowledge-based health education has failed.

USA: Sexuality and HIV education. This study was implemented in four schools in New York City with ninth and eleventh grade students (867 students) in intervention (an AIDS prevention program) and control classes (no AIDS prevention program). The program focused on correcting facts about AIDS, teaching cognitive skills to appraise the risk of transmission, increasing knowledge of AIDS-prevention resources, changing perceptions of risk-taking behavior, clarifying personal values, understanding external influences, and teaching skills to delay intercourse and/or consistently use condoms. An evaluation carried out three months after the end of the program found that the intervention group presented the following positive behavioral outcomes when compared with the control group: decrease in intercourse with high- risk partners, increase in monogamous relationships, and an increase in consistent condom use (Walter and Vaughan 1993).

Nigeria: HIV/AIDS prevention. Health education programs are being implemented in many schools in Nigeria to increase levels of knowledge, influence attitudes, and encourage safe sexual practices among secondary school students. A study to evaluate one such program compared 223 students who received comprehensive sexual health education with 217 controls. Students in the intervention group received six weekly sessions lasting two to six hours, with activities including lectures, film shows, role-play stories, songs, debates, essays, and a demonstration of the correct use of condoms. Following the intervention, students in the intervention group demonstrated a greater knowledge and increased tolerance of people with AIDS compared to the control. The mean number of sexual partners also decreased in the intervention group, while the control group showed a slight increase. The program was also successful in increasing condom use (Fawole et al 1999).

USA: A cognitive-behavioral approach to substance abuse prevention. The effectiveness of a 20-session cognitive-behavioral approach to substance abuse prevention was tested on seventh grade students (n=1,311) from 10 suburban New York junior high schools. The prevention strategy attempted to reduce interpersonal pressure to smoke, drink excessively, or use marijuana by fostering the development of general life skills as well as teaching students tactics for resisting direct interpersonal pressure to use these substances. In addition, this study was designed to compare the relative effectiveness of this type of prevention program when

February 2002 implemented by either older peer leaders or regular classroom teachers. Results indicated that the prevention program had a significant impact on cigarette smoking, excessive drinking, and marijuana use when implemented by peer leaders. Furthermore, significant changes were also evident with respect to selected cognitive, attitudinal, and personality predisposing variables in a direction consistent with non-substance use. These results provide further support for the efficacy of a broad-spectrum smoking prevention strategy and tentative support for its applicability to the prevention of other forms of substance abuse (Botvin et al 1984).

USA: School-based drug abuse prevention program. A randomized control trial, involving over 3,000 students in 56 public schools, implemented a drug abuse prevention program, teaching general life skills and skills for resisting social influences to use drugs. Follow- up data were collected six years after the initial baseline survey. Significant reductions were found for both drug and polydrug (tobacco, alcohol, and marijuana) use in the groups receiving the prevention program, compared to the control groups. The conclusion from this study was that drug abuse prevention programs conducted during junior high school can produce significant and durable reductions in tobacco, alcohol, and marijuana use if they (i) teach a combination of social resistance and general life skills, (ii) are properly implemented, and (iii) include at least two years of booster sessions (Botvin et al 1995).

3. Context for Implementing Skills-based Health Education with HIV/AIDS Prevention

Although there is strong evidence that skills-based HIV/AIDS prevention is effective when properly applied and supported, implementing this approach and achieving this success on a larger, countywide scale is one of the greatest challenges. To be effective, HIV/AIDS prevention programs must address the following areas:

Reassure stakeholders that these messages are beneficial. Talking and teaching about reproductive health and HIV/AIDS issues does not result in earlier initiation of sex or promiscuity. The evidence suggests that well implemented, skills-based programs, conducted in an atmosphere of free discussion of all the issues, is likely to lead young people to delay the initiation of intercourse and to reduce the frequency of intercourse and the number of sexual partners (Kirby et al 1994; UNAIDS 1997a).

Provide support to teachers. The lack of support for implementation of new programs is one of the most important factors affecting success. For most teachers both the content and methods of HIV/AIDS prevention programs are new and perhaps sensitive and yet the approach has great potential to assist teachers both in their work and their personal lives since HIV/AIDS is, of course, also affecting teachers. Sufficient support, training, practice, and time need to be available to teachers, in both pre- and in-service training sessions and workshops, to facilitate reflection and development of teachers’ personal attitudes and to motivate them to apply their new knowledge and skills, rather than continue with the more didactic, traditional teaching methods, which are often focused on information alone (Gatawa 1995; Gachuhi 1999). In addition, sufficient time and an appropriate place must be provided in the curriculum so that all students have access to HIV/AIDS prevention.

Start early. In addition to targeting adolescents, programs should be targeted to children at an early age, with developmentally appropriate messages, before they leave school (Gachuhi 1999; Partnership for Child Development 1998). Because younger children are generally not sexually active, these programs will establish the building blocks for healthy living and avoiding risk, rather than addressing the very specific issues related to sexual relationships and HIV/AIDS, which are progressively introduced into programs for older children. The large number and diverse age range of children within primary schools is an enduring challenge, however,

February 2002 especially when addressing sensitive issues (Partnership for Child Development 1998). Active and self-directed learning methods that are commonly used in skills-based health education can be helpful in overcoming these classroom management issues to some extent.

Provide a supportive environment. Schools need to have strong policies and a healthy supportive environment in terms of student behavior towards one another, teachers, and school personnel. Sexual abuse can occur in schools, with both boys and girls reporting abuse by school staff (Kinsman et al 1999; Lowensen et al 1996). Programs must address this potential problem by training and supporting teachers, so that they can become role models rather than neutral or adverse figures in relation to sexual behavior.

Respond to local needs. Many of the models for HIV/AIDS prevention have been developed in Western, developed countries. The available evidence from developing countries, although more limited in scope than the studies from non-developing countries, supports skills- based health education for HIV/AIDS and reproductive health (Hubley 2000). The main issue is that wherever programs are to be implemented they must be shaped to meet the local sociocultural norms, values, and religious beliefs and need to include ongoing monitoring (Kirby et al 1994; UNAIDS 1999; Kinsman et al 1999).

4. Elements of a Skills-based Health Education for HIV/AIDS Prevention

Reviews of school-based HIV/AIDS prevention programs (23 studies in the USA (Kirby et al 1994), 37 other countries (reported in UNAIDS 1999), and 53 studies in the USA, Europe and elsewhere (UNAIDS 1997a) have identified the following common characteristics of successful programs:

 Focus on limited and specific behavioral goals, such as delaying initiation of intercourse or using protection and that involve knowledge, attitude, and skill objectives.

 Provision of basic, accurate information that is relevant to behavior change, especially detailing the risks of unprotected intercourse and methods for avoiding this behavior.

 Reinforcement of clear and appropriate values to strengthen individual and group norms regarding unprotected sex.

 Modeling and practice in communication and negotiation skills as well as other related “life skills.”

 Use of Social Learning theories as a foundation for program development.

 Addressing social influences on sexual behaviors, including the important role of media and peers.

 Use of participatory activities (games, role-playing, group discussions, etc.) to achieve the objectives of personalizing information, exploring attitudes and values, and practicing skills.

February 2002  Extensive training for teachers/implementers to help them master the basic information about HIV/AIDS, to practice, and to gain confidence in life-skills training methods.

 Support for reproductive health and HIV/STD-prevention programs used by school authorities, decision, and policy makers, as well as the wider community.

 Evaluation (e.g., of outcomes, design, implementation, sustainability, school, student, and community support) so that programs can be improved and successful practices encouraged.

 Appropriate messages for various ages, targeting students in different age groups and developmental stages with messages that are relevant to young people and suitable for each age group. For example, one goal of targeting younger students, who are not yet sexually active, might be to delay the initiation of intercourse, whereas the emphasis for sexually active students might be to reduce the number of sexual partners and to use condoms.

 Gender sensitivity for both boys and girls.

5. Additional Case Studies

Zimbabwe: AIDS Action Program for Schools. Zimbabwe has one of the highest AIDS prevalence rates in Africa and young people are particularly at risk from HIV infection and other unwanted effects of unprotected sex. By age 19, 44% of adolescent females are either pregnant or have given birth, indicating a high rate of unprotected sex (Ndlovu and Kaim 1999). In 1992, the Ministry of Education and Culture initiated a Life Skills Education Program, in collaboration with UNICEF, for schools (AIDS Action Program for Schools). The program is aimed at students and teachers in grades 4 to 7 in all primary schools and in grades 1 to 6 in all secondary schools. It aims to develop pupils’ life skills such as problem solving, informed decision making, and avoidance of risky behavior, using participatory and experiential teaching and learning processes.

Over 2,000 teachers have been trained (using pre-service and a cascade model of in- service training) and the program is taught in over 6,000 schools, with equal status as other curriculum subjects. Supporting textbooks and teaching materials have been developed and the program has the full support of government and other influential groups such as churches (Gatawe 1995; Gachuhi 1999).

Challenges for this program include level of teacher training, skills, experience, and confidence. A review in 1995 found that only one-third of teachers had received any in-service training. Teachers were unfamiliar with life skills and participatory and experiential learning techniques. Many found the sensitive topics of sex and HIV embarrassing and difficult to teach.

Zimbabwe: “Auntie Stella” Reproductive Health Education. The “Auntie Stella” health education pack for secondary school students was developed following research by the Training and Research Support Centre (TARSC) in its Adolescent Reproductive Health Education Project (ARHEP); it also drew on the experience of the AIDS Action program. Using participatory research methodology, the ARHEP program identified knowledge and major concerns of students (e.g., fear of rape and sexual harassment, unwanted pregnancy, lack of money leading to coercive sexual relationships, fear of STDs and AIDS) regarding reproductive health, along with sources of help and information available to the students.

February 2002 “Auntie Stella” is a classroom-based pack consisting of question and answer cards based on the format of magazine helpline letters (identified by ARHEP as being among the chief sources of information for reproductive health for adolescents). This format helps students identify and analyzes their behavior, including risk-taking behavior and situations. Students then take part in exercises to help them devise “Action Plans” and suggest ways that their behavior could be altered to reduce risk. “Auntie Stella” has been field tested in eight pilot schools and, based on the evaluation and recommendations flowing from the program, the effort will be expanded to a national level, taking “Auntie Stella” to other schools throughout the country (Ndlovu and Kaim 1999).

The initial reaction to the “Auntie Stella” pack by both students and teachers has been positive and encouraging. The Ministry of Education and Culture supports expanding the program. The next phase of program evaluation will concentrate on the impact of “Auntie Stella” on behavior to see if students are actually implementing the Action Plan points developed through “Auntie Stella.” Challenges for the program include helping the students devise and practice realistic strategies and skills for avoiding risky behavior.

Lima, Peru: HIV/AIDS prevention in secondary schools. A skills-based education program on sexuality and HIV/AIDS prevention was designed taking into account Social learning Theory and constructs of machismo and openness towards sexuality. Fourteen schools were randomly assigned as interventions and controls. The intervention schools implemented seven weekly two-hour sessions, which included discussions, verbal exercises, role-playing, and familiarization with condoms/contraceptives and lectures. Homework promoted interaction with family, friends, and local health institutions. Trained teachers from the schools facilitated the program. When compared with the control group, the intervention group showed significant changes in knowledge on sexuality and AIDS, openness towards sexuality, acceptance of contraception, tolerance of people with AIDS, self-efficacy, and prevention-orientated behaviors (Caceres et al 1994).

Colombia: Risk factors for adolescents. Life skills training is promoted by the Department of Human Development of the Ministry of Health as part of a health promotion strategy that addresses some of the most important risk factors of children and adolescents, including school drop out, child labor, early sexual activity and adolescent pregnancies, delinquency, violence, and substance abuse. In 1996 Fe y Alegria, an international NGO, began implementation of a pilot project using WHO Life Skills training materials, adapted to a Colombian context. The pilot covered six schools in three regions (1,260 students aged 10 to 15, 500 parents, and 45 teachers). The project included teacher training and workshops, extracurricular activities, and work with parents. Although the users have not yet completed full evaluations of the project, teachers, parents, and pupils initially indicated favorable outcomes, including positive changes in behavior, decreased levels of aggression, greater ability to speak openly and cope with emotions, and a high acceptance of life skills methods (Meresman et al 2000).

Vietnam: HIV/AIDS prevention. A skills-based HIV/AIDS prevention project was begun as a UNICEF-assisted HIV/AIDS prevention project of the Vietnam Ministry of Education and Training (MOET) in 1997. The project was undertaken in the context of rapid social and economic change in the last decade and reflected concerns in the health sector with access and equity and a growing concern among health officials with the threat of HIV/AIDS. The primary goal of this project was to equip young people with the information and skills needed to make often difficult decisions that would allow them to lead healthy lives, especially in relation to HIV/AIDS/STD risk. A pilot life skills teaching approach was implemented in schools, with teachers trained and supported in skills-based health education. The major focus was on student

February 2002 knowledge, attitudes, values, and behaviors—with an anticipated outcome that the program would also have a positive impact on teaching staff.

According to an evaluation at the completion of the pilot phase of the project, students demonstrated increased knowledge of HIV/AIDS and its transmission, increased knowledge of ways to avoid infection, improved tolerance, and improved decision-making skills. Teachers also showed an improved level of knowledge and found that the interactional teaching techniques were a great improvement over more traditional didactic methods. A UNAIDS evaluation of the project also confirmed that the program had been effective for both students and teachers in terms of building confidence, knowledge, and abilities. This evaluation suggested the need to gather future information on student sexual behavior such as contraceptive use, community and national pregnancy rates, and rates of STD infection to evaluate the impact of the project on behavior change (UNAIDS 2000).

Tanzania: The Lushoto Enhanced Health Education Project. In 1998, the Tanzania Partnership for Child Development carried out a study in the Lushoto district of Tanzania (the Lushoto Enhanced Health Education Project (LEHEP)), focusing on worm infection and personal hygiene, involving teacher-led, innovative and active, participatory health education methodology. A randomly selected group of schools was chosen to implement the project and compared with a set of randomly elected schools that were not adopting the LEHEP approach. An evaluation of the program offered good evidence of improved knowledge and practices in the intervention schools, but not in the control schools, particularly with reference to the provision of safe drinking water, water for hand washing, general environmental cleanliness, and health awareness. At the outset of the project, no schools provided drinking water or water for hand washing after using the latrine. By the end of the first year, all schools in the intervention area were doing both. A follow-up survey 15 months after the end of the project year found that many of the healthy behaviors adopted in the intervention schools were still maintained (Lansdown et al 2001).

6. The Way Forward

Skills-based health education, promoted in a supportive framework such as that offered by the FRESH schools initiative, offers an effective approach to equipping children and young people with the knowledge, attitudes, and skills that they need to avoid risk-taking behavior and adopt healthier life styles. The scope of skills-based health education can be applied to a wide range of problems, especially STD and HIV/AIDS prevention, but also violence, substance abuse, and such unwanted situations as early pregnancy, water and sanitation-related diseases, and all areas in which knowledge, attitudes, and skills play a critical role in combating disease and promoting a healthy lifestyle for children and young people growing up in the 21st century.

References

Botvin, G.J., E. Baker, N. Renick, A.D. Filazzola and E.M. Botvin. 1984. “A cognitive- behavioral approach to substance abuse prevention.” Addictive Behaviors 9:137-147.

Botvin, G.J., E. Baker, L. Dusenbry, E.M. Botvin and T. Diaz. 1995.” Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population.” Journal of the American Medical Association 273(14): 1106-1112.

Caceres, C.F., A.M. Rosasco, J.S. Mandel and N. Hearst. 1994. “Evaluating a school-based intervention for STD/AIDS prevention in Peru.” Journal of Adolescent Health 15: 582-591.

February 2002 Drake, L.J., M.C.H. Jukes, R.J. Sternberg and D.A.P. Bundy. 2000. “Geohelminth infections (Ascariasis, Trichuriasis and Hookworm): Cognitive and developmental impacts.” Seminars in Pediatric Infectious Diseases 11, 245-251.

Fawole, I.O., M.C. Asuzu, S.O. Oduntan, W.R. Brieger. 1999. “A school-based AIDS education program for secondary school students in Nigeria: a review of effectiveness.” Health Education Research—Theory and Practice 14: 675-683.

Gachuhi, D. 1999. “The impact of HIV/AIDS on education systems in the Eastern and Southern Africa region and the response of education systems to HIV/AIDS: Life Skills Programs.”

Gatawa, B.G. 1995. “Zimbabwe: AIDS education for schools.” Case study. UNICEF, Harare, Zimbabwe.

Hubley, J. 2000. “Interventions targeted at youth aimed at influencing sexual behavior and AIDS/STDs.” Leeds Health Education Database, April 2000.

Kelly, M.J. 2000. “Standing education on its head: Aspects of schooling in a world with HIV/AIDS.” Current Issues in Comparative Education 3(1).

Kinsman, J., S. Harrison, J. Kengeya-Kayondo, E. Kanyesigye, S. Musoke and J. Whitworth. 1999. “Implementation of a comprehensive AIDS education program for schools in Masaka District, Uganda.” AIDS CARE 11(5): 591-601.

Kirby, D., L. Short, J. Collins, D. Rugg and others. 1994. “School-based programs to reduce sexual risk behaviors: a review of effectiveness.” Public Health Reports 109(3): 339-361.

Lansdown and others. 2001. “Schistosomiasis, helminth infection and health education in Tanzania: achieving behavior change in primary schools.” Health Education Research (in press).

Lowensen, R., L. Edwards and P. Ndlovu-Hove. 1996. “Reproductive health rights in Zimbabwe.” Training and Research Support Centre (TARSC).

Meresman, S., D. Bundy and M.T. Cerqueira. 2000. Paper on school health programming in Latin America. Draft.

Ndlovu, R. and B. Kaim. 1999. “Adolescent reproductive health education project: lessons from ‘Auntie Stella’—Reproductive health education in Zimbabwe’s secondary schools. Part One. (Report, May 1999).

Partnership for Child Development. 1997. “Better health, nutrition and education for the school- aged child.” Transactions of the Royal Society of Tropical Medicine and Hygiene 91: 1-2.

———. 1998. “Implications for school-based health programs of age and gender patterns in the Tanzanian primary school.” Tropical Medicine and International Health 3(10): 850-853.

Stoltzfus, R.J., M. Albonico, J.M. Tielsch, H.M. Chwaya and L. Savioli. 1998. “School-based deworming yields small improvement in growth of Zanzibari school children after one year.” Journal of Nutrition 128, 2187-2193.

UNAIDS. 1997a. “Impact of HIV and sexual health education on the sexual behavior of young people: A review update.”

February 2002 ———. 1997b. “Learning and teaching about AIDS at school.” UNAIDS technical update, October 1997.

———. 1999. “Sexual behavioral change for HIV: Where have all the theories taken us?”

———. 2000. “Innovative approaches to HIV prevention.”

UNAIDS/WHO. 1999. “AIDS epidemic update: December 1999.”

Walter, H. and R. Vaughan. 1993. “AIDS risk reduction among a multiethnic sample of urban high school students.” JAMA 270(6): 725-730.

WHO. 1996. “Strengthening interventions to reduce helminth infections: An entry point for the development of health-promoting schools.” WHO/HPR/HEP/96.1.

———. 1999. “Preventing HIV/AIDS/STI and related discrimination: an important responsibility of health promoting schools.” WHO series on school health, document six.

———. 2000. “Local Action: creating health promoting schools.” WHO series on school health.

February 2002 IV. Core Intervention 4: Access to Health and Nutrition Services

The FRESH framework, an intersectoral initiative to Focus Resources on Effective School Health, provides the context for effective implementation of access to health and nutrition services within school health programs. School-based health and nutrition services, such as micronutrient supplementation and deworming, are likely to be most effective when they are supported these additional strategies: policies to provide a non-discriminatory, safe, and secure environment, the provision of safe water and sanitation, effective referral to external health service providers and links to the community. The FRESH framework provides this context by positioning access to health and nutrition services among the four core components considered an essential requirement for all schools: I. Health-related school policies II. Safe water and sanitation III. Skills-based health education IV. Access to health and nutrition services These core components to the FRESH framework require school-community partnerships to be the supporting strategies for the success of school health and nutrition programs. The programs rely on effective partnerships between the health and education sectors, teachers and health workers, schools and community groups, and between the pupils and those responsible for implementing school health programs.

There are now more school-age children in developing countries than ever before, due to population growth and the success of child survival programs. At the same time, there are more children in the schools because access to basic education has increased in most of the developing world. Still, millions of school-age children remain at risk due to poor health and nutrition. There is increasing recognition that the common conditions of ill health among school children can be managed effectively, simply, and inexpensively through school health and nutrition programs when they include school-based health and nutrition services, health, and hygiene education and the provision of safe water and sanitation.

1. Why School-based Health and Nutrition Services?

School health programs and services help link the resources of the health, education, nutrition, and sanitation sectors in an existing infrastructure to the school. While the school system in most developing countries is rarely universal, coverage is generally superior to that of the health systems and the school provides an extensive skilled workforce (teachers and administrators) that already works with the local community.

School-based health and nutrition services provide simple and easily administered school-based health and nutrition services, such as micronutrient supplements (including vitamin A, iron, and iodine) and anthelmintics with which teachers can treat parasitic helminth infections. As such, they offer schools an effective way to improve the health and nutritional status of children (Partnership for Child Development 2000; Mwanri et al 2000; Beasley et al 2000), especially when they are supported by the provision of adequate water as well as sanitation and health and hygiene education.

February 2002 Data from several studies show that the prevalence of stunting increased with age, indicating a higher proportion of stunted, school-aged children. It also appears that adolescent boys are more sensitive to infection and diseases than girls and thus are more malnourished. In addition, studies have shown that linear growth continues beyond the normal puberty growth period. This suggests that school-based programs aimed at improving health and nutrition status may have the potential to bring about catch-up growth in stunted, school-aged children (Stoltzfus et al 1998).

As more countries adopt universal basic education strategies, they increase enrollment and reduce absenteeism and dropout, bringing more of the poorest and most disadvantaged children to school. Happily, many of these new school attendees are girls. The new male and female students are often the least healthy and most malnourished and have the most to gain educationally from improved health (Odaga and Heneveld 1995; Bundy and Guyatt 1996).

School-based health and nutrition services are highly cost-effective: the cost of drugs for treating parasitic worms in the Partnership for Child Development’s school health programs in Ghana and Tanzania was typically about US$0.40 per year per child treated for albendazole (to treat soil-transmitted helminthiasis) given annually, plus praziquantel (schistosomiasis) given every two years. The cost of two capsules of iodized oil—each providing 200 mg of iodine, enough for a typical primary school child—was about US$0.40 (Partnership for Child Development 1999).

These services also can provide an entry point for wider school-based health programming, such as delivery of skills-based health and nutrition education, improvements to water and sanitation facilities, and the wider involvement of the local community and other key stakeholders. Interviews and discussions with children, parents, and implementers in Tanzania and Ghana have found that the large majority agrees with the role of schools and teachers in school-based health service delivery and a willingness by parents to meet either part or all of the costs. Both the family and the community view the delivery of health and nutrition services through schools as a positive activity in their community (Partnership for Child Development 2001).

Beyond the benefits to both the family and community, school-based health services that impact on poor health and nutrition are likely to benefit society as a whole. The consequences of stunting caused by malnutrition include increased morbidity and mortality, poor physical and mental development and school performance, and reduced body size and capacity for physical growth—all of which have long-term economic and societal implications. School health programs that target poor health and nutrition are therefore an investment in a country’s people and their capacity to thrive both economically and as a society (Stephenson, Latham, and Ottesen 2000).

2. School-based Health and Nutrition Services: Deworming

The World Health Organization (WHO) estimates that more than one billion of the world’s population is chronically infected with soil-transmitted helminthes and 200 million are infected with schistosomes. Global prevalence and number of cases of intestinal helminth infection in school-age children are estimated at: Roundworm 35% (320 million); Whipworm 25% (233 million); Hookworm 26% (239 million) (Partnership for Child Development 1997).

February 2002 Exposure and susceptibility to worm infections are not uniform and, as Figure 4 demonstrates, the school-age child is most at risk from intense infections. Because intensity of infection is directly related to morbidity, it is clear that the school-age child is most at risk from disease. In developing countries, these worm infections account for an estimated 12% of the total disease burden for girls and boys aged 5 years and for 11% of the group when they reach 14 years of age; the worm infections represent the single largest contributor to the disease burden of the 5- 14 year age group (Bundy 1988). A community survey in Jamaica showed, for example, that 90% of the total worm population for intestinal nematodes occurred in children between 5 and 15 years of age.

Figure 4. Worm Infection by Age (adapted from Bundy 1988)

100

80

d e t c e f 60 n i

e g a t

n 40 e c r e P 20 Ascaris Trichuris Hookworm

0 0 10 20 30 40 50 60 Age (years)

Because children are most at risk when they are both growing and learning, geohelminth infection potentially threatens a child’s overall physical and psychological development. Parasitic helminth infection may cause or aggravate malnutrition and retard child development (Stephenson, Latham, and Ottesen 2000).

Anthelmintics may reverse growth and nutritional deficits caused by even modest worm infection. Intervention studies have shown that infection with as few as 10 roundworms is associated with growth deficits in school-age children and that moderate whipworm infections can cause growth retardation and anemia. In more severe cases, children infected with Trichuris dysentery syndrome show “catch-up growth” after treatment of intense whipworm infections and other intervention studies have shown a positive impact on anthropometrical parameters and iron status of preschool and school-age children with helminth infections (Drake et al 2000).

Physical ill health caused by parasitic helminth infection negatively affects a child’s mental function. There is a proven link between iron deficiency anemia, stunting, and cognitive development. In addition, although the evidence is as yet inconclusive, it is likely that helminths impair cognitive development. However, this may occur only for those children with the heaviest parasitic loads or for those already vulnerable in other ways, such as from undernourishment (Drake et al 2000).

February 2002 The high prevalence of infections and the development of effective and safe single-dose treatments for worms have led WHO to recommend that the schools offer mass treatment when surveys show that the prevalence of intestinal helminths or schistosoma infections exceeds 50% (WHO 1998). The recommended treatments are albendazole or mebendazole for roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura), and hookworm (Necator americanus, Ancylostoma duodenale) and praziquantel for treating schistosomes.

In addition, population dynamic theory has predicted that focusing a treatment effort on this age group will significantly reduce transmission in the population as a whole (Bundy et al 1990). Large-scale field studies have supported these conclusions. A school-based program in Montserrat treated 95% of schoolchildren on a regular basis, producing a decline in intensity in both the treated children and the untreated population outside the school (Bundy et al 1990). In Kenya, treating only schoolchildren had almost the same impact on S. mansion re-infection rates, as did a comprehensive program that sought to treat the entire population. Population dynamic models of these data suggest that these observations can be satisfactorily explained only by the assumption that schoolchildren are the major contributors to helminth transmission (Chan and Bundy 1997).

Outline a school-based deworming program

The Partnership for Child Development, based in the UK, is developing a Toolkit that describes how children in primary schools can be treated for schistosomiasis and intestinal helminths as a part of a School Health Program. Deworming may also be part of a package of school health interventions such as the provision of micronutrient supplements, including combined vitamin A and iron supplementation (Mwanri et al 2000). The Toolkit is based on the experiences of school health programs developed by PCD and is briefly outlined below:

1. A situation analysis is the first step in a school health program, which may include the use of geographic information systems and remote sensing technologies to study the spatial and temporal patterns of helminth infections in a given country or region (Brooker and Michael 2000). Once the targeted area is determined, it can be useful also to review the current knowledge about the health and nutrition of school-age children in that area. There may be existing data or reports that can help to guide a school health program in general or a deworming program in particular (Partnership for Child Development 1999).

2. Before the program begins, the whole community must be made aware of the need for treatments, the methods for providing them, and the benefits that will accrue to children’s health and development.

3. Education officials should train teachers how to administer drugs to children. Side effects may occur after treatment, but these are generally mild and short-lived Teachers are trained to deal with these and should be able to refer children to the local health center.

4. For the treatment of urinary schistosomiasis, a simple health questionnaire, administered by teachers to their pupils, identifies schools in which prevalence is high enough for all children to receive treatment with praziquantel. This school health questionnaire also identifies individual children who need treatment in schools where urinary schistosomiasis is less common.

February 2002 5. A small, randomized survey of schools is conducted involving the collection and analysis of stool samples by trained parasitologists (for the detection of intestinal helminthiasis). This is used to determine the prevalence of infection in a region.

6. If the estimated prevalence of infection for either schistosomiasis or intestinal helminthiasis in a school is greater than 50%, the World Health Organization recommends the treatment of all children in the school (WHO 1992). This strategy is called “mass treatment.”

7. Treatment of intestinal helminthiasis commonly calls for albendazole or mebendazole. In cases of high prevalence, biannual and even triennial treatment may be necessary (Stoltzfuzs et al 1998). For schistosomiasis, the number of tablets of praziquantel required by each child can be calculated, using height rather than weight, because of the close correlation of height and weight. By standing a child upright against a pole, health workers can calculate the number of tablets the child needs by reading the pole. PCD has shown that the dose of praziquantel given this way is within safe and acceptable limits (Hall et al 1999).

8. Studies have shown that combined mass treatment of schoolchildren with praziquantel and albendazole produced no more side effects than treatment with praziquantel alone. Albendazole was not associated with any measurable side effects above the level seen in children treated with praziquantel (Olds et al 1999).

9. On the day of treatment and throughout the process, local health centers and health personnel are prepared to provide support to schools and teachers.

Case Studies

Zanzibar: School-based deworming program and improvement in growth. The Zanzibar Ministries of Health and Education implemented a school-based deworming program on Pemba Island that was evaluated by the Centre for Human Nutrition of Johns Hopkins School of Public Health. Schoolchildren in grades one through four in 12 randomly selected schools were chosen for evaluation and allocated to the control, twice-yearly, or thrice-yearly treatment groups, with approximately 1,000 children in each group. Before the study began, meetings were held at each school to inform parents of the deworming regime, the purpose of the evaluation, its risks and benefits, and alternatives to participation in the surveys. The Centre conducted baseline, six- month and 12-month follow-up nutrition and phraseology surveys, inviting all children present in school on survey days to participate in each survey. Overall, 91% of children participated in the baseline survey and 85% of those children were assessed again at the 12-month follow-up.

Children who received thrice-yearly mebendazole were compared with children who received twice-yearly mebendazole and with untreated children. The evaluation found that children younger than ten gained 0.27 kg more weight and 0.13 cm more height in the twice yearly group and 0.20 kg more weight and 0.30 cm more height in the thrice-yearly group, compared with the control group. Children younger than 10 with greater height-for-age at baseline had greater weight and height gains in response to deworming. In children 10 and older, overall program effects on height or weight gains were not significant. However, in this age range, younger boys made significant gains in height with thrice-yearly deworming and children with greater height-per-age had greater gains in weight and deworming.

In conclusion, the evaluation provided evidence that the school-based deworming program improved the growth of schoolchildren. The pre-post design of the evaluation, the

February 2002 comparison between randomly allocated program and control schools, and statistical adjustments for the differences in baseline characteristics among groups supported evaluator conclusions that periodic anti-helminthic treatments caused greater height and weight gains among children participating in the program (Stoltzfus et al 1998).

Jamaica: Treatment for whipworm and mental development. An experimental study conducted in Mandeville, south central Jamaica, among schoolchildren of both sexes, aged 9 to 12, with moderate to heavy whipworm burden, found improvements in working memory and long-term scanning and retrieval two months after treatment (Nokes et al 1992). This study focused on 104 children with a moderate to heavy worm burden of T. trichiura (whipworm). Each child assigned to the treatment group received one dose for three days of albendazole following initial cognitive testing. The control and placebo groups each received a matching placebo.

The functions affected by infection were related to attentiveness and appeared to involve both auditory short-term memory and the scanning and retrieval of long-term memory. This study is the first to demonstrate that moderate to heavy infection by whipworm has a detrimental and reversible effect on certain cognitive functions in children (Nokes et al 1992).

Indonesia: Association between helminths and cognition. A study in Java, Indonesia, conducted by the Indonesia Partnership for Child Development investigated the association between helminth infection and cognitive and motor function in school-aged children. Participating in this study were 432 children, male and female, from two age groups (one was 8 and 9 years, and the other was 11, 12, and 13 years) and 42 primary schools. The study found that helminth infection, in particular hookworm infection, of school-age children is associated with lower cognitive function scores. Children infected with hookworm scored significantly lower on tests of cognitive function compared with uninfected children (WHO in press).

Mali: Evidence of the link between Schistosoma haematobium, school performance, and attendance. This study was carried out in two primary schools in Bamako, Mali. The schoolchildren, frequently 6 to 11 years old, lived in areas with poor hygienic conditions and no regular water or electricity supplies. The studies enrolled 580 children (51% female, 49% male), each of whom provided one stool and one urine sample. All positive cases of schistosomiasis were treated with a single dose of praziquantel and geohelminth infections were treated with a single dose of mebendazole. Infection with S. haematobium was, by far, the most common helminth infection. Overall, 537 children provided data on both intensity of S. haematobium infection and academic performance. A significant decline in academic performance was noted with increasing infection intensity.

Data on both absenteeism from school and infection with S. haematobium were available for 466 of the children. Significant increases in absenteeism were found with increasing age. In addition, there was a significant interaction between the effect of absenteeism, gender, and intensity of infection on academic performance, indicating that the reduction in academic performance with increasing intensity of infection cannot be dissociated from that of absenteeism (D. de Clercq et al 1998).

3. School Health and Nutrition Services: Micronutrient Supplements

In developing countries, growth retardation results not only from infection but also from malnutrition. Even in severe and prolonged cases of growth retardation, however, malnutrition and growth retardation may be reversed (Mwanri et al 2000).

February 2002 The four most important forms of global malnutrition are iron deficiency anemia (IDA), vitamin A deficiency (VAD), protein energy malnutrition (PEM), and iodine deficiency disorders. Malnutrition is associated with (estimated) over half of all child deaths in developing countries (Stephenson 1987).

All forms of global malnutrition may impact on the physical and psychological development of the school-age child. Nokes, Van den Bosch, and Bundy point out that there is strong evidence that among school-age children, lower scores on tests of cognition or school achievement due to iron deficiency anemia can be improved and in some cases reversed after iron treatment (Nokes et al 1998). In fact, the authors examined 11 studies of the effects of iron supplementation on the cognitive functions or educational achievement of school-age children with iron deficiency or iron deficiency anemia and concluded that this evidence suggests that the treatment of IDA in preschool and school-age children through iron supplementation programs may be beneficial and have immediate effects (Nokes et al 1998).

Deficiencies of micronutrients such as iron, vitamin A, and iodine are a major problem in developing countries. Micronutrient deficiencies can negatively effect mental development and the learning ability of children and their susceptibility to infection.

Iron deficiency and anemia. Iron deficiency affects more people in the world than any other form of malnutrition. It is estimated that 60 million school-age children suffer from iron deficiency disorders while some 120 million suffer from iron deficiency anemia (IDA) (Del Rosso and Marek 1996). IDA results from a variety of causes, including inadequate iron intake, high physiologic demands in early childhood and pregnancy and iron losses from parasitic infections. In developing regions of the world, the prevalence of IDA in 5-12 year-olds is estimated to be 46% with the highest rates found in Africa (49%) and South Asia (50%) (Stoltzfus et al 1997). IDA in infants and young children is associated with significantly lower scores on psychological tests and also leads to long-term deficits in cognitive functioning (Drake et al 2000). Iodine. Iodine deficiency affects an estimated 1.6 billion people worldwide and an estimated 60 million school-age children. The consequences of iodine deficiency, collectively referred to as iodine deficiency disorders (IDD), include severe mental retardation, goiter, abortion, stillbirths, low birth weight and mild forms of motor and cognitive deficits. Adolescent girls are an important target group for IDD control because of the adverse consequences on fetal development of iodine deficiency during pregnancy and because they generally have a higher prevalence of goiter than boys do. Vitamin A. Vitamin A deficiency is widely recognized as an important cause of blindness in children. Mild or sub-clinical vitamin A deficiency causes impaired immune function and an increased risk of mortality from infectious diseases that can have an effect on school attendance and consequently on academic performance. It is estimated that 85 million school-age children are at increased risk of acute respiratory and other infections because they are deficient in vitamin A (Del Rosso 1999). Vitamin A deficiency also affects iron metabolism so that with any iron supplements taken, subsequent improvement in iron status may be limited when vitamin A status is low. This is increasingly recognized as a potential constraint when considering the impact of school-based iron supplementation.

February 2002 Case Studies

Tanzania: Vitamin A supplements improve anemia and growth. A study of 136 anemic children conducted in three primary schools in Bagomoyo District of Tanzania found that children given combined vitamin A and iron supplements experienced significant increases in hemoglobin levels after three months. Most (88%) of the children who received both vitamin A and iron were not anemic after three months of supplementation, compared with only 3% of the placebo group (Mwanri et al 2000).

Jamaica: Nutritional supplementation, psychosocial stimulation, and improvements in the mental development of stunted children. A study in Kingston, Jamaica, assessed the effects of nutritional supplementation, with or without psychosocial stimulation, of growth- retarded (stunted) children aged 9-24 months. One hundred and twenty-nine children from poor neighborhoods were randomly assigned to four groups: control, supplemented only, stimulated only, and supplemented and stimulated. The supplement consisted of one kg. of milk-based formula per week for two years and the stimulation consisted of weekly play sessions at home with a community health worker. The children’s development was assessed on the Griffiths mental development scales. Stimulation and supplementation had significant independent beneficial effects on the children’s development. The study found that combined interventions were more effective than either alone. These findings suggest that poor mental development in stunted children is partially attributable to undernutrition (Grantham-McGregor et al 1991).

USA: Cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls. Iron deficiency is not limited to the developing world. In the USA, up to 25% of adolescent girls is iron deficient. Eighty-one girls with non-anemic iron deficiency from four Baltimore high schools participated in this study. Participants were randomly assigned oral ferrous sulphate or placebo for eight weeks. The effect of iron treatment was assessed by questionnaires and hematological and cognitive tests, which were done before treatment started and after the intervention. Post-intervention measures of iron status were significantly improved in the treatment group. The study found that girls who received iron performed better on a test of verbal learning and memory than girls in the control group (Bruner et al 1996).

4. School Health and Nutrition Programs: Examples

Tanzania: Ushirikiano wa Kumwendeleza Mtoto Tanzania (UKUMTA) and the effect of deworming on schoolchildren. The Tanzanian Partnership for Child Development (UKUMTA) was established in 1994 with the aim of promoting the health and education of school-age children in Tanzania, furthered through four main activities:

 Large-scale operations research on treatment programs for intestinal helminths in the Tanga region involving 110,000 children.

 Developing and improving pictorial health education materials to strengthen the health education curriculum.

 Monitoring and evaluating the effects of interventions in the Tanga Region in terms of health, growth, micronutrient status, and education of primary school children as well as the processes and costs of delivering these interventions.

 Applied research studies on the health and education of school-age children including: the Makwami project, which examines the effects of treating parasitic infections on the cognitive process in children and their education achievement; a

February 2002 study of children not enrolled in school; and a study of perceptions of pictures used in health education materials in schools.

UKUMTA is supported by four ministries: Education and Culture; Health; Community Development, Women Affairs, and Children; and the Office of Local Government. Various Tanzanian medical and educational institutions provide technical assistance to the program, with the advice of the Scientific Coordinating Centre of the Partnership for Child Development, based in the UK.

One of the main activities of UKUMTA is a large-scale demonstration school health program that delivered school health services to over 110,000 children in all 352 schools in three districts of the Tanga Region. In 1996 and 1997, the Ministry of Education, in collaboration with the Ministry of Health, coordinated the delivery by the teachers of two rounds of free treatment albendazole and praziquantel to the children.

Questionnaire Survey and Baseline Study

UKUMTA has been instrumental in developing innovative tools and methods for school health programs. At the onset of the program, UKUMTA developed and delivered a questionnaire survey about ill health, which teachers administered to pupils in 639 schools in the Tanga Region. The data were used to select schools for the baseline survey and to examine children’s self- reported health problems (such as kichocho or urinary schistosomiasis). The survey revealed that the children had a poor perception of their health status and almost all identified at least one health problem in the previous two weeks.

The questionnaire survey was followed by a baseline survey of 1396 children from 41 schools. The survey found that 77% of children in Tanzania were classified as anemic and over one-half showed evidence of mild iodine deficiency or worse. Most children showed evidence of chronic rather than acute under-nutrition, with 70% of children classified as stunted and 54% as underweight. Eighty-six percent of children were infected with at least one parasitic helminth, with 63% of children infected with hookworm.

After the first round of treatment, another health survey was conducted. About 1,000 new children were examined in the three intervention districts and all were treated. These children were compared with another 1,000 children in the comparison districts who had not participated in the UKUMTA program. The survey found the following:

 Re-infection of urinary schistosomiasis was low;  Anemia was significantly less common among the children who had been treated with albendazole and praziquantel and  There was evidence of better growth of children after treatment. In addition to the questionnaire survey, special poles to measure height (as a proxy for weight) were adapted and used by UKUMTA as a simple and inexpensive alternative to weighing scales (too fragile and expensive for many low-income countries) to determine the appropriate dose of praziquantel to be delivered by teachers to treat schistosomiasis (Hall, Nokes, Wen et al 1999).

Burkina Faso: Save the Children (USA) and School Health Activities. School-based health services are essential elements of Save the Children’s (SC/US) School Health and Nutrition activities in more than 13 countries in Africa, Asia, Latin America, and the Middle East. These activities may include micronutrient supplementation (vitamin A, iodine, and iron),

February 2002 deworming for intestinal parasites and schistosomiasis, school nutrition programs, the provision of first aid kits, screening and treatment of eye infections, and classroom remediation for vision and hearing impairments.

To ensure that interventions respond to local needs, SC/US and the Ministry of Health, with technical support from the Institut National de Recherche en Sante Publique in Mali, carried out a situation analysis in eight SC/US community schools in Burkina Faso’s Bazega Province. The situation analysis found that school-aged children in Bazega Province suffer from high rates of malnutrition, micronutrient deficiencies, and parasitic infections, inhibiting both mental and physical development. Based on these results, Save the Children (USA) in collaboration with the local Ministry of Health and Ministry of Education launched a School Health and Nutrition program in 24 SC/US community schools in Bazega Province in 1999, expanding to another 34 formal schools. The program now reaches nearly 15,000 schoolchildren and is set to expand to other provinces.

The program’s school-based health services include annual treatment for intestinal parasites with albendazole and praziquantel for schistosomes and the provision of vitamin A and iodine. In addition, school-based health services are supported by skills-based health education and the provision of both latrines and safe drinking water.

One year after the start of the program, an evaluation conducted in five community schools found that there had been a significant impact on the prevalence of malnutrition, anemia, worm, and schistosome infection, as well as a substantial improvement in school performance and attendance. The prevalence of malnutrition and anemia dropped by one-third, schistosomiasis infection fell by one-half, overall worm infection by 15%, and night-blindness decreased from 5.9% to 0.7%. In addition, there was a 30% improvement in the end-of-year exam results and a 20% improvement in school attendance, with both improvements sustained in the second year of the program.

Discussions conducted by SC/US with both parents and children have found that school- based health services, particularly micronutrient supplementation and deworming, are seen as a substantial benefit to school and consequently improve attendance and enrolment. As one teacher put it: “Now parents want their children to go to school because at school their health is taken care of.”

5. The Way Forward

School-based health and nutrition services are more likely to benefit the health and nutritional status of schoolchildren when delivered in the context of a framework for improving the health of schoolchildren such as that provided by the FRESH partnership. School-based health and nutrition services are an integral part of the school health approach provided in the FRESH framework and should exist along with health-related school policies, the provision of safe water, sanitation, and skills-based health education. The provision of safe water, sanitation, and hygiene education are particularly important, as these are the long-term solutions to combating helminth infection.

Based on the school health experiences of the FRESH partner agencies, the guidelines for a successful school program state that programs benefit from effective partnerships between schools and the community and between the education and health sectors. In addition, the delivery of health and nutritional services through schools must be simple, safe, and familiar and address problems that are both prevalent and recognized as important within the community.

February 2002 References

Azene, G., H. Guyatt, S. Brooker, A. Hall and D.A.P. Bundy. 1999. “The cost of large-scale school health programs which deliver anthelmintics to children in Ghana and Tanzania.” Acta Tropica 73: 183-204.

Beasley, N.M.R., A.M. Tomkins, A. Hall, W. Lorri, C.M. Kihamia and D.A.P. Bundy. 2000. “The impact of weekly iron supplementation on the iron status and growth of adolescent girls in Tanzania.” Tropical Medicine and International Health 5(11): 794-799.

Brooker, S. and E. Michael. 2000. “The potential of geographical information systems and remote sensing in the epidemiology and control of human helminth infections.” Advances in Parasitology 47: 245-288.

Bruner, A.B., A. Joffe, A.K. Duggan, J.F. Casella and J. Brandt. 1996. “Randomized study of cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls.” Lancet 348: 992-996.

Bundy, D.A.P. and H. Guyatt. 1996. “Schools for health: focus on education and the school-age child.” Parasitology Today 12(8): 1-16.

Bundy, D.A.P., M.S. Wong, L.L. Lewis and J. Horton. 1990. “Control of geohelminths by delivery of targeted chemotherapy through schools.” Transactions of the Royal Society of Tropical Medicine and Hygiene 84: 115-120.

Chan, M.S. and D.A.P. Bundy. 1997. “Modeling the dynamic effects of community chemotherapy on patterns of morbidity due to Schistosoma mansoni.” Transaction of the Royal Society of Tropical Medicine and Hygiene 91(2): 216-220.

De Clerq, D., M. Sacko, J. Behnke, F. Gilbert and J. Vercruysee. 1998. “The relationship between Schistosoma haematobium infection and school performance and attendance in Bamako, Mali.” Annals of Tropical Medicine and Parasitology 92(8): 851-858.

Del Rosso, J.M. 1999. “School Feeding Programs: Improving effectiveness and increasing benefit to education.” Partnership for Child Development, London.

Del Rosso, J.M. and T. Marek. 1996. Class Action. Improving School Performance in the Developing World through Better Health and Nutrition. Washington, DC: World Bank.

Drake, L.J., M.C.H. Jukes, R.J. Sternberg and D.A.P. Bundy. 2000. “Geohelminth Infections (Ascariasis, Trichuriasis and Hookworm): Cognitive and Developmental Impacts.” Seminars in Pediatric Infectious Diseases 11(4): 245-251.

Draper, A. 1997. “Child development and iron deficiency. Early action is critical for healthy mental, physical and social development.” INACG.

Hall, A., C. Nokes, S. Wen, S. Adjei, C. Kihamia, L. Mwanri, E. Bobrow, J. Graft-Johnson and D.A.P. Bundy. 1999. “Alternatives to bodyweight for estimating the dose of praziquantel needed to treat schistosomiasis.” Transactions of the Royal Society of Tropical Medicine and Hygiene 93: 653-658.

Mwanri, L., A. Worsley, P. Ryan and J. Masika. 2000. “Supplemental vitamin A improves anemia and growth in anemic schoolchildren in Tanzania.” Journal of Nutrition 130: 2691-2696.

February 2002 Nokes, C., S.M. Grantham-McGregor, A.W. Sawyer, E.S. Cooper, B.A. Robinson and D.A.P. Bundy. 1992. “Moderate to heavy infections of Trichuris trichiura affect cognitive function in Jamaican schoolchildren.” Parasitology 104: 539-547.

Olds, G.R., C. King, J. Hewlett and others. 1999. “Double-blind placebo-controlled study of concurrent administration of albendazole and praziquantel in schoolchildren with schistosomiasis and geohelminths.” The Journal of Infectious Diseases 179: 996-1003.

Partnership for Child Development. 1999. A situation analysis. A participatory approach to building programs that promote health, nutrition and learning in schools. Oxford, UK: Partnership for Child Development.

———. 2000. “What’s new in the health and nutrition of the school-age child and in school health and nutrition programs?” Paper prepared for ACC/SCN, April 2000.

———. 2001. “Community perception of school-based delivery of anthelmintics in Ghana and Tanzania.” Tropical Medicine and International Health (in press).

Stoltzfus, R.J., M. Albonico, H.M. Chwaya, J.M. Tielsch, K.J. Schulze and L. Savioli. 1998. “Effects of the Zanzibar school-based deworming program on iron status of children.” American Journal of Clinical Nutrition 68: 179-186.

Stephenson, L. 1998. Impact of Helminth Infections on Human Nutrition. London: Taylor & Francis.

Stephenson, L.S., M.C. Latham and E.A. Ottesen. 2002. “Malnutrition and Parasitic Helminth Infections.” Parasitology (in press).

Grantham-McGregor, S.M., C.A. Powell, S.P. Walker, J.H. and Himes. 1991. “Nutritional supplementation, psychosocial stimulation and mental development of stunted children: The Jamaican study.” Lancet 338: 1-5.

WHO. 1992. Health of school children: treatment of intestinal helminths and schistosomiasis. WHO/CDS/IPI/CTD/92.1.WHO, Geneva.

———. 1998. Guidelines for the evaluation of soil-transmitted helminthiasis and schistosomiasis at community level. WHO/CTD/SIP/98.1 WHO, Geneva.

———. Controlling disease due to helminth infections. WHO, Geneva.

February 2002 V. Cost of School Health Interventions

1. Cost of School Health Programs

In a recent review of health interventions, the Bank concluded that school health is one of the “Best Buys” for Bank clients. School health interventions are especially appropriate for pursuing Education for All goals in developing countries because school health activities require few additional investments. Because each of the four principal activities that form the core interventions of the FRESH framework rely on existing structures of the Ministries of Education and Health, school nutrition and health programs can be among the most cost-effective health interventions. Most important, these simple interventions are beneficial to the poorest of the targeted population groups.

Health sector specialists have evaluated the value and costs of various health interventions in terms of Disability Adjusted Life Years (DALYs) including school health programs, as shown in this table.

Health intervention Cost per DALY % Total Indicate cost gained (1990 global disease in US$ annual US$) burden cost per capita averted EPI plus 12-30 6% 0.50 School health & nutrition 20-34 0.1% 0.30 Family planning services 20-150 3% 0.90 Integrated management of 30-100 14% 1.60 childhood illnesses (IMCI) Prenatal & delivery care 30-100 4% 3.80 Tobacco & alcohol prevention 35-55 0.1% 0.30 Sources: Del Rosso 1996; Clareson, Mawji, and Walker 2000.

The different interventions have various cost implications. Here are some examples of actual costs involved in the implementation of activities for each of the four principal axes of FRESH.

2. Cost of School Health Policies

To have an effective school health program, the policies and regulations concerning the health and nutrition of school-aged children have to be well known and understood by not only the administrators but also by the teachers, parents, and children throughout the country. This requires a strategic communication plan entailing various expenses. The costs of communication plans will differ based on the extent that media and operational research are used.

In Chad, the school health unit plans to implement an intensive campaign to reach the communities in rural and urban centers through out the vast country. Funds needed will be approximately $50,000 per year or $200,000 per four years for expenses including technical assistance, seminars, debates, conferences, brochures, posters, television, and radio transmissions. Approximately $150,000 for five years has been budgeted to reach the population of Mauritania. In Guinea, $375,000 was requested for four years to create and implement a wide-reaching strategic communication plan. Finally, the typical cost of preparing and implementing a Communication for Behavior Change program can be viewed as a proxy for the costs of strategic communication programs. An effective program including formative research, strategy

February 2002 formulation, preparation of materials, and implementation can cost from US$110,000 to US$750,000 depending on the size of the country and scope of issues.

3. Cost of Water and Sanitation Installations

The construction of latrines and installation of water points can be extremely costly. With advocacy and collaboration with school construction units, however, the actual cost to the school health program is relatively low. The costs of the installations differ greatly because of environmental differences and models used.

Latrines per school Water (approximate costs) (approximate costs) Senegal US$1200 US$300 (urban) Mauritania US$500 US$16,000 to US$1,000 Chad US$1100 US$700 to US$3,500

In addition to the construction and installation of water points and latrines, there are other costs that can be adopted by the school health unit. The costs of maintenance could be borne by the community or considered as an addition to the budget. The Senegal school health team estimates US$300 per school for maintenance. The school health team in Guinea estimates that the testing of wells will cost approximately US$30 per well, which the Guinea team has included as an important part of the school health team’s work. In general, the school health unit would be responsible for monitoring the latrines and sanitation facilities in schools as well as training the community members for proper maintenance. Communities can also contribute to the construction of sanitation facilities.

4. Cost of Life Skills Programs

Health education for the improvement of health, hygiene, and nutrition is essential to the effectiveness of school health programs. Lessons on hygienic practices or HIV/AIDS prevention by behavior change require new curriculum development and teacher training. These activities require heavy investment in the beginning but less for sustained implementation.

 In Vietnam, a health education program was implemented in 25 schools in combination with deworming services. The intervention area covered 18,898 children and 583 teachers. The costs of planning (two workshops), training of all the teachers, producing and distributing children’s booklet and teachers’ guides, providing on- going teacher support and incentives, and monitoring activities, including steering committee meetings and school visits totaled, US$36,796 or US$1.94 per child reached. Of the total, the cost per teacher for training is US$8.92. The costs represent the development period and implementation during one school year—approximately seven months (Vietnam Partnership for Child Development 2000).

 In the US, each US$1 invested in education about the hazards of tobacco use saves an estimated $18.80 in the costs required to address the problems associated with smoking. A US$1 investment in programs aimed at the prevention of drug and alcohol abuse yields savings of US$5.69. A US$1 investment in education to prevent unprotected sexual behavior saves US$5.10 (Del Rosso and Markek 1996).

Recently, there have been attempts to estimate the money required to halt, or make significant inroads into, the AIDS epidemic in Africa, by expanding intervention prevention

February 2002 programs to become effective in terms of prevention and support for effected individuals and their families at the population scale. There are considerable challenges in arriving at these estimations and in setting prevention and care targets that are both affordable and realistic. For example, most available information currently comes from small-scale projects and it is unlikely that either the unit cost or the likely outcomes of these projects would remain the same if scaled up to a national level. It also difficult to ascertain the exact relationship between behavior change and new infection rates at different levels of HIV prevalence and in different populations.

 A school-based HIV, STD, and pregnancy prevention program in a US setting estimated that for every dollar invested in the program, $2.65 in total social and medical costs was saved (Wang et al 2000).

 In Kenya, a radio program delivering Family Life Education and aimed at young people, cost US$0.03 for each adolescent reached and US$0.12 per adolescent reporting behavior change as a result of participating in the program (UNAIDS 1999a).

 In Zimbabwe, the AIDS Action Program for Schools, supported by UNICEF, promotes life-skills HIV/AIDS prevention for teachers and pupils. The additional cost of one child-year of AIDS education through this program was estimated at US$0.16 (UNAIDS 1999b).

A recent economic analysis by ACTAfrica (2001) estimates the cost of scaling up coverage of school-based and out-of-school HIV/AIDS prevention programs. The analysis estimates the average unit cost of teacher training and simple materials necessary for the implementation of such programs as US$75 to US$200 (for primary school teachers) and US$121 to US$241 (for secondary school teachers). Assuming these costs and an increase in coverage of from 40% to 60% over five years, the study estimates the total cost of scaling up HIV/AIDS activities (from 2000 to 2005) for Sub-Saharan Africa as a whole. For youth-focused interventions, both in school and out, the estimated range is from US$211million to US$313million for HIV/AIDS prevention.

5. Cost of Health Service Delivery

Many different services can be delivered through the education system. Again the existing school system is used to reduce costs of delivering the various interventions; however, some can be more costly than others.

Deworming and micronutrient supplementation. A detailed cost analysis of delivery of albendazole and praziquantel in the school-based programs in Ghana (80,442 children in 577 schools) and Tanzania (110,000 children in 352 schools) has been described by Partnership for Child Development. The total financial costs per treatment per child (cost of drugs plus delivery) of a combination of mass and selective treatment for schistosomiasis using praziquantel, which also involved prior screening at the school level, was US$1.22 in Ghana and US$0.79 in Tanzania. The costs of treating intestinal nematodes with albendazole which was given as a fixed dose to all children was US$0.24 in Ghana and US$0.23 in Tanzania. The largest component of this cost in most cases was the drugs themselves, with delivery forming a smaller proportion of the total cost. The exception was the cost of delivery of praziquantel in Ghana, which was slightly higher than the cost of the drug; because dosage of praziquantel is individualized additional training was necessary.

February 2002 In addition to deworming, vitamin supplementation is necessary to improve the health status of the malnourished children. Vitamin A capsules cost US$0.02 per dose—with two doses per year, so that US$0.04 per student would be needed. Iodine costs approximate US$0.30 to US$0.40 per dose/one dose per year. Thus, a year’s worth of iron (10 weekly tablets) is less than US$0.10. These are only the costs of the drugs. The costs of shipping, handling, and internal delivery as well as training of teachers would be additional. If, however, the micronutrients were combined with an established deworming program, much of the needed infrastructure would exist and, therefore, additional costs would be minimal. Based on this assumption, deworming with iron supplementation would cost approximately US$1.00 or deworming with (albendazole and praziquantel) and micronutrients (Iron, Iodine, Vitamin A) approximately US$1.50 per student per year.

Cost of drugs (per Cost of delivery child per yearly dose Albendazole for Ghana, Tanzania, US$0.03-0.20 US$0.03 intestinal worms and India Praziquantel for Ghana, Tanzania US$0.20-0.71 US$0.21-0.54 Schistosomiasis Vitamin A US$0.04 Iodine US$0.30-0.40 Iron US$0.10 TOTAL US$0.67-1.45 > US$0.24-0.57 Sources: Del Rosse 1996; Partnership for Child Development 1999; World Bank 2001; World Bank forthcoming.

Presumptive treatment of malaria. In a small pilot area in Malawi, Save the Children (US) has been treating students for malaria with Fansidar. In this area of Malawi, presumptive malaria treatment by health clinic workers has been required for those with basic symptoms such as fever because of the nature of malaria in Malawi, as well as the growing resistance of the disease to chloroquine. Fansidar has a one-dose application that makes treatment easier. The pilot program, which provides the schools with first aid kits that include Fansidar, offers a feasible alternative in Malawi to chloroquine, which was given as a standard of care by health agents in health clinics. The cost for Fansidar is US$0.80 for two tablets, which is the treatment dosage. Panadol (US$0.16 for two tablets) is also administered with Fansidar. In addition to the costs of the drugs and delivery of them to the school, costs for training teachers, and sensitisation would have to be considered.

Periodic examinations. The KwaZulu-Natal Province, South Africa, has 5,000 schools with an enrolment of 2.8 million pupils. Many of the schools are in rural areas with limited access to health facilities. The school nurse:pupil ratio ranges from 1:1,000 in urban areas to 1:9,000 in rural areas. Health teams, led by a trained nurse, aimed to visit each enrolled child at least once during his/her years at primary school. Evaluations revealed that only 10.7% of school health teams visited all of their target schools. In one rural region, only 36% of schools were visited. The service was able to screen 18% of the province’s pupils. About 11% of school health teams carried out the required follow-up with their target schools. The cost of the program was US$11.5 per child screened, excluding costs of referral and follow up.

More effective screening and referral services within school health programs have been realized when properly trained teachers, instead of health workers, have been used in the screening process. An excellent example of this is a school health program in Chile, which was entirely based on the role of teachers in the schools and linked to the health system by effective

February 2002 referral. This approach can work only where there is an effective health care system to which children can be referred. This program achieved 96% coverage at US$1.8 per child treated.

A full medical visit is estimated to cost about US$7 per child in Senegal. This estimate is based on previous experience of schools in the capital cities of the regions of Senegal in which medical staff was available and they did not have to travel far to see the students. The cost represents the real costs of the examination but does not take into account possible follow-up such as the costs of treatment.

School feeding. “A comparison of the costs of school feeding programs is problematic. The number of days of feeding varies, as does the quantity of the rations and their quality. When cross-country cost information is standardized by controlling for some of these differences, the data show that the cost of school feeding programs ranges from $19.25 to $208.59 per 1,000 calories per student for 365 days (1989 dollars). The mean program cost was $88.74, the median $81.46” (Horton 1992).

A similar study of three Sub-Saharan Africa countries revealed similar costs—from US$43.12, US$79.68, and US$171.43. Without the costs of the food, which are often donated, these program costs were US$17.24, US$23.75, and US$56.05 per 1,000 kcal per child per day for 365 days. Based on the assumption that the school year is about 180 days (6 schooldays x 30 weeks) or half of the 365 days, the cost of delivery only of 1,000 kcal per child per the school year would be US$8.60, US$11.90, and US$28 per year.

Country Ration Days Cost per Number of Cost per (Kcal) per 1000kcal/day/ Beneficiaries school year year 365/days/year (180 days) (delivery & (delivery & food) food) Bolivia 325 165 $53.53 N/A $26.77 Ecuador 365 165 $61.10 200,000 $30.55 Guatemala 456 165 $19.25 1,093,000 $09.63 Honduras 180 165 $24.38 594,393 $12.19 Paraguay 324 165 $208.29 76,493 $104.15 Burkina 1,109 160 $43.12 315,000 $21.56 Faso Cape Verde 760 189 $171.43 73,000 $85.72 The Gambia 850 200 $79.68 83,000 $39.84

Some have tried school snack programs as alternatives to traditional school feeding programs. In a program in Indonesia, for example, locally produced snacks are provided at a cost of US$0.10 to 0.15 per ration per day (approximately US$18 to $27 per school year—180 days). In South Africa, a breakfast program using local food was implemented at US$0.33 per child per day or approximately US$59 per school year—at 180 days. In Bolivia, a snack program consisting of fortified bread and hot chocolate costs in total US$4 per child per year.

References

Action Plans and Budgets. Education Projects (IDA) of School Health Teams of Chad, Guinea, Mauritania, and Senegal.

February 2002 Clareson, M, T. Mawji and C. Walker. 2000. Investing in the Best Buys: A Review of the Health, Nutrition and Population Portfolio, FY1993-1999. Washington, DC: The World Bank.

Del Rosso, J.M. and T. Marek. 1996. Class Action: Improving School Performance in the Developing World through Better Health and Nutrition. Washington, DC.: The World Bank.

Del Rosso, J. 1999. “School Feeding Programs: Improving Effectiveness and Increasing the Benefit to Education. A Guide for Program Managers.” The Partnership for Child Development.

Favin, M. and M. Griffiths. 1999. Using Communication to Improve Nutrition: A Guide for World Bank Task Managers. Washington, DC: World Bank.

HDNHE. 2001. “School Health at a glance.” Wasjomgtpm DC: World Bank.

Partnership for Child Development. 1999. “The Cost of Large-scale School Health Programmes Which Deliver Anthelmintics to Children in Ghana and Tanzania.” Acta Tropica 73, 183-204.

Plans of action and budgets for education projects (IDA) by school health teams of Chad, Guinea and Mauritania.

Program Learning Group. Presentation, August 2001. Oxford, England. Save the Children Malawi.

Sembene, Dr. Malick, Coordinator, School Health Program, MOE Senegal. No date. Personal communications.

UNAIDS. 1999a. UNAIDS Best Practices: School AIDS Education Category. The Kenya Youth Initiatives Project.

―――. 1999b. UNAIDS Best Practices: School AIDS Education Category. The Kenya Youth Initiatives Project.

Vietnam Partnership for Child Development. 2000. Unpublished Manuscript.

Wang, L.Y. M.A. Davis, M.L. Robin, J. Collins, K. Coyle and E. Baumler. 2000. Economic Evaluation of Safer Choices: School-based Human Immunodeficiency Virus, Other Sexually Transmitted Diseases and Pregnancy Prevention Program. Arch. Pediatr. Adolesc. Med. 154:1017-1024.

World Bank. Forthcoming. A Window of Hope: Education and the Global Epidemic of HIV/AIDS, HDNED, World Bank: Washington DC.

World Bank. Forthcoming. “Rationale for School-Based Health Services.” International School Health Initiative.

World Bank. Forthcoming. School Health and Nutrition Document Series. International School Health Initiative.

February 2002 Section 3. Terms of Reference (TORs) for Preparing School Health and Nutrition Programs

A variety of work products from different sectors is required during preparation of school health components as indicated in the following examples:

3.1 A TOR for a technical study of the health status of school-age children for the education sector in Chad;

3.2 A Statement of Mission Objective (SMO) for a pre-identification mission for a school health and nutrition component for the education and health sectors working cooperatively in Mozambique; and

3.3 A TOR for a detailed situation analysis for the education sector in Tanzania.

February 2002 3.1 TOR for Health Survey for Education Project in CHAD

Anticipated results: Geographical distribution of parasitic infections (urinary and intestinal) and micronutrient deficiencies (iodine, vitamin A, and iron.); determine distribution and prevalence of parasitic infections (urinary and intestinal) and deficiencies among Chad children of school age.

Tasks:

1. Determine geographic and demographic survey targets. Determine initiative targets on the Chad map.

2. The consultant will be responsible for putting together a team of investigators. The national team survey will be supported with the appropriate technological means.

3. Implementation of the survey:

 Locally analyze urine for bilharziasis.  Locally analyze stools for intestinal parasites.  Reserve urine specimens for iodine measurements in N’Djamena.  Conserve blood and blood samples.  Locally determine hemoglobin levels.  Reserve blood serums for vitamin A measurements in N’Djamena.  Measure goiters.  Measure anthropometric parameters (weight and size).  The survey will use approximately 1,000 children in 20 schools.

4. All surveyed infected children will receive the necessary treatments.

5. Use the Iodine Deficiency Study results (conducted by CNNTA, WHO, UNICEF).

6. Implement questionnaire systems to determine bilharziasis among students.

February 2002 3.2 Statement of Mission Objectives (SMO) for Pre-identification Mission for Education Sector in MOZAMBIQUE

From 00/00 to 00/00, the consultant, supported by the Danish Trust Fund, will travel to Mozambique to work on pre-identification of a school health and nutrition component in the education sector.

The Government of Mozambique (GOM) has already identified the significant contribution of the education system to health and nutrition. Earlier work examined the role of the school in HIV prevention and malaria control. The GOM policy matrix under the Education Sector Strategy Paper listed the issues of hunger-related absenteeism and the introduction of a school-feeding program as key objectives and actions.

Joint analysis by WHO, UNICEF, UNESCO, and the World Bank identified school health and nutrition programs as a cost-effective way to respond to the priorities identified by GOM. These partners in school health are providing support to countries to increase the quality and quantity of school health programs, which are seen as urgent and important because of the impact of HIV and malaria on the education system.

School health is relatively underdeveloped in Mozambique. It is suggested that the key needs in this area are policy development and a needs assessment related to policy, structure, and implementation issues.

The Danish Trust Fund of the World Bank has provided grant support for a pre- identification mission to Mozambique. Further support is available for capacity building in school health and nutrition.

The main objectives will be to work with GOM on:

1. Institutional Issues

Explore the existing actions between the MOH, MOE, and other relevant ministries in school health and nutrition and assess the potential basis for future activities across ministries.

2. Programmatic Issues

Assess how existing health-related school policies function. Developing policies around the following areas may become especially relevant: school girls who become pregnant, students who are infected with HIV, and the general issues of smoking and abuse. Identify the curriculum components concerning hygiene education and collect information on the provision of safe water and sanitation in schools in rural areas. Explore causes of absenteeism.

Assess what is being done in the area of skills-based health education and current activities among school children and out-of-school youth to prevent HIV/STDs and unwanted pregnancies.

Assess current school-based health and nutrition services, such as school meals, nutrition education, malaria prophylaxis, deworming, or regular contact with community health services.

Identify potential future activities in all the above areas.

3. Situation analysis on health and nutrition of school children.

February 2002 Collect available statistical data on the health and nutrition status of school children.

Desegregated data from poor, rural areas will be especially relevant.

4. Partnerships.

Meet with UN partners in Maputo including UNICEF, WHO, UNESCO, UNFPA, UNAIDS, and WFP to identify the current situation and possibilities for future collaboration in school health programs.

Along with Save the Children efforts, contact other NGOs working in the field of school health or in other community and education activities to identify the current manpower situation and the available resources for supporting school health activities.

At the end of the mission, an Aide Memoire will be drafted and shared with the ministries and other UN partners.

February 2002 3.3 TOR for Situation Analysis for Education Sector in TANZANIA

1. Background

The Government of Tanzania is now preparing a sector-wide education project to be funded by the World Bank and to meet the objective of improving quality and access to primary education for all children of Tanzania. The strategic goals as defined in the project document are as follows:

 Improvement of quality, as measured by enhanced learning achievement and good instructional practice;

 Equitable provision of learning opportunities;

 Strengthened central-, district-, and school/community-level capacity to manage the delivery of education services and to monitor performance;

 Allocation of adequate public funding to operate an effective, responsive primary education system and to ensure the sustainability of reforms and innovations introduced to improve teaching learning outcomes.

Poor health and malnutrition are significant causes of low school enrollment, absenteeism, poor classroom performance, and early school dropout, as reflected in the World Declaration on Education for All. Therefore, the proposed school health component of this project can make an important contribution to achieving the strategic goals of the education project.

It is essential that an effective education system ensure that children are healthy and able to learn. This is especially the case for the Education for All program in the most deprived areas. Increased enrollment and reduced absenteeism and dropout bring more of the poorest and most disadvantaged children to school, many of whom are girls. It is these children who are often the least healthy and most malnourished with the most to gain educationally from improved health. Effective school health programs developed as part of community partnerships provide an exceptionally cost-effective method for reaching adolescents and the broader community. More important, they are a sustainable means of promoting healthy practices.

Good health and nutrition are not only essential inputs but also important outcomes of basic education of good quality. First, children must be healthy and well nourished to fully participate in and gain the maximum benefits of an educational program. Early childhood programs and primary schools that improve children’s health and nutrition can enhance the learning and educational outcomes for school children. Second, education of good quality can lead to better health and nutrition outcomes for children, especially girls and thus for the next generation of children as well. In addition, a healthy, safe, and secure school environment can help protect children from health hazards, abuse, and exclusion.

In addition to the positive educational outcomes, school health programs can mitigate the effects of HIV/AIDS on the education system. Effective policies can respond to the growing numbers of orphans and can support children and teachers affected by AIDS. Effective preventive activities can reduce HIV transmission for both children and teachers and can promote and establish life-long healthy practices.

February 2002 The Government and the communities of Tanzania have a long history and extensive experience in implementing school health activities. School health programs have existed since the colonial period, although often in a form that favored the more affluent senior secondary school student over the child in basic education. Since the 1980s, the Government of Tanzania has worked internally and with external partners to reform and modernize their school health programs. UNICEF, UNAIDS, Irish AID, and CIDA are some of the partners that have assisted in the operational research and implementation of various school health and nutrition activities in Tanzania.

This experience has demonstrated that there are major health and nutrition problems that serve to constrain the learning and educational achievements of school-aged children and prevent them from taking full advantage of the educational opportunities that are offered to them. The research also shows that these constraints can be effectively addressed through the school system in Tanzania. Current and recent activities, however, have addressed these needs in pilot areas rather than through a systematic national programmatic approach.

The new sector-wide education project provides an opportunity for the various partners implementing school health activities in Tanzania to develop and launch a coordinated national school health program. A partnership of UNESCO, UNICEF, WHO, the World Bank, and others is working with governments in Africa to develop a planning framework that can help identify the most cost-effective approaches to school health, with the aim of Focusing Resources on Effective School Health, hygiene and, nutrition. This “FRESH” framework seeks to support governments in developing a program of locally relevant and uncomplicated school health activities that can be implemented in all schools in support of the goals of Education for All (EFA). Positive experiences by WHO, UNICEF, UNESCO, and the World Bank suggest that these are cost- effective activities that are the basis for healthy schools for children. Many of the current school health activities of Tanzania are already included in the FRESH framework.

In developing a progressive plan for school health in Tanzania, the key partners will use the FRESH framework as a basis for dialogue. A situation analysis will be prepared, based on existing evidence, identifying the major soluble health and nutrition problems of school-age children in Tanzania, with particular emphasis on those conditions that constrain learning and educational achievement. The analysis will also identify the major experiences of health and nutrition intervention through the school system in Tanzania. This analysis will be prepared in partnership with the key players in school health in Tanzania and will provide the basis of sector- wide and cross-sectoral discussions leading to a plan of action to develop a national school health and nutrition strategy.

2. Summary

A local consultant will work with the Ministry of Education and the key partners in school health to develop the Situation Analysis and Plan of Action for the school health activities for the education reform project.

The National Institute of Medical Research (NIMR) will provide technical data on health and nutrition status of school-age children.

An international consultant will provide Quality Assurance for the documents and will take the lead in building partnerships with the potential key partners in school health.

February 2002 3. Products

A. Situation Analysis

The analysis will describe, to the extent possible based on currently available information, the health and nutrition status of school-age children in Tanzania. It will focus on the conditions known to constrain learning and educational achievement, including data on educational patterns and participation. The analysis will focus on information about the behaviors and practices of school children that are known to place them at risk of ill health, including STD/AIDS. In addition, the analysis will include a review of current policies on health factors within the education system, especially with regard to HIV/AIDS. In preparing this document, every opportunity will be taken to access unpublished information from all key partners. The National Institute of Medical Research will be a lead partner in data discovery.

The analysis will also describe past, present, and planned actions to promote, improve, or otherwise enhance the health and nutrition status of school-age children, especially those implemented through the education system. As far as possible, a detailed inventory of partners who have contributed to school health in Tanzania will be prepared.

Using the FRESH framework, the analysis will also identify practicable, sustainable interventions that are likely to most improve children’s health, nutrition, attendance, and educational achievement; identify major gaps in and problems with existing school nutrition and health services, and identify issues requiring further investigation.

This analysis will explore not only government activities, but activities implemented by all other partners, including the UN system (especially UNICEF, WHO, UNESCO, UNAIDS, WFP), bilaterals (especially DFID, GTZ, Irish AID, USAID, CIDA, SIDA, NORAD), civil society (international and local), and the community and community organizations. Special attention should be paid to activities that are related to HIV/AIDS prevention.

For detailed guidance on the preparation of a situation analysis for school health, refer to “School Health and Nutrition: A Situation Analysis” prepared by the Partnership for Child Development with UNICEF, WHO, USAID, World Bank, and others and available in Kiswahili as “Uchanganuzi wa Heli.”

B. Plan of Action

With the problems and activities identified, it is necessary to proceed to the next steps. The partners will use the situation analysis and the FRESH framework to identify continuing and future roles. It would be useful at this point if an outline were developed that listed ways to combine and coordinate the technical and financial resources and strengths of each of the partners to continue through the next implementation phases. The Plan of Action will address how the programs can be scaled up nationally and what kind of coordination is needed for effective scale- up. It is anticipated that a process of capacity building and detailed planning at the district or other peripheral level will be a necessary stage in the rollout.

An overall Plan of Action will be developed with input from all partners and will illustrate the range of inputs and resources available to a future national program. The Government of Tanzania will be supported in preparing a specific Plan of Action in the context of the general education project.

February 2002 An indicative budget will be prepared; this budget is detailed for the first year and more general for the next four years of the project. The Plan of Action will outline how to support the activities at the district level and explain how these activities will be coordinated to achieve national coverage. The Plan will specifically address the issue of intersectoral coordination amongst sector ministries, especially the Ministries of Education and Health.

4. Specific Tasks and Responsibilities

The local consultant will prepare the Situation Analysis and Plan of Action. S/he will coordinate with the international consultant and the National Institute of Medical Research in preparing both of the above. S/he will be guided by the international consultant in arranging liaison with partners and will make all necessary arrangements for the visits of the international consultant to at least those partners specifically mentioned in Section 3 above. S/he will liaise with the project team under the leadership of Donald Hamilton and with the School Health Team at the World Bank.

The National Institute of Medical Research will seek and provide to the consultants such documents and technical information and data at national, regional, and district levels that they can discover that is germane to school health and nutrition in Tanzania.

The international consultant will provide technical assistance and quality assurance at all stages. This consultant will provide technical assistance to develop solid partnership among various donors and partners by assisting in meetings and leading discussions with them. S/he will also provide quality assurance by providing a technical review of the final draft of the proposed Plan of Action and Situation Analysis. S/he will liaise with the project team under the leadership of Donald Hamilton and with the School Health Team at the World Bank.

5. Supervision

This work will be supervised and coordinated by ______with the assistance of ______, acting on the advice of ______, Task Team Leader. They will prepare the appropriate contributions to the PAD, including project description summary, Annex 2, and cost tables.

6. Duration of Mission and Budget

The mission must occur, at least in part, during the period November 15 to December 15, 2000, when the Task Team Leader will be present in Tanzania. The final draft (approved by the international consultant) of the Situation Analysis and the Plan of Action must be made available by January 8, 2001.

A. Local consultant

It is expected that the local consultant will spend 20 days coordinating, gathering, meeting, discussing, analyzing, and writing the reports.

Budget: Consultant Fee = (Daily fee X 20 days) plus local travel and per diem for travel outside of his/her domicile.

February 2002 B. The National Institute of Medical Research will provide 10 days of a staff time

Budget: NIMR will be supported for travel and per diem for work performed outside of the Dar Es Salaam office and actual costs for materials.

C. The international consultant will work with the consultant for five days

Budget: Consultant Fee = (Daily fee X 5 days) plus per diem, lodgings, local travel, and travel to/from Tanzania.

7. Qualifications

A. Local Consultant

Experience in education assessment and in health services delivery based in schools. S/he should also have a working knowledge of the various levels of government, especially of the district system.

B. International Consultant

Experience in school health programs, cognitive assessment and the measurement of educational achievement, practical experience of related work in Tanzania, and functional in Kiswahili.

8. Details of Technical Content of Documents

The following elements summarize the FRESH framework and are intended as guidance for the consultants in developing the technical aspects of the project component.

A. Policies on School Health

Health policies in schools, including skills-based health education and the provision of some health services, can help promote the overall health, hygiene, and nutrition of children. However, good health policies should go beyond this to ensure a safe and secure physical environment and a positive psychosocial environment and should address issues such as abuse of students, sexual harassment, school violence, and bullying.

Studies in neighboring countries indicate that one often cited reason for girls’ dropping out has been the sexual demands of teachers and administrators from girls in exchange for grades. Have there been any studies or surveys to indicate that this might be a problem also in Tanzania? Policies that help to prevent and reduce harassment by other students and even by teachers also help to remove the reasons for which girls withdraw or are withdrawn from schools.

By guaranteeing the further education of pregnant schoolgirls and young mothers, school health policies will help promote inclusion and equity in the school environment. Do policies concerning pregnant girls that prevent or lower attendance of girls exist? Policies regarding the health-related practices of teachers and students can reinforce health education: teachers can act as positive role models for their students, for example, by not smoking in school. Are there policies addressing the issue of tobacco in schools? Teachers smoking in class? Vendors selling cigarettes?

February 2002 The process of developing and agreeing upon policies draws attention to these issues. The policies are best developed by involving people at many levels, policy makers representing the nation, and teachers, children, and parents representing the schools.

What other policies exist or are needed for the health and welfare of the children, according to the community members, the students, nurses, teachers, etc.? If clear policies do exist, is there a system or a strategy for disseminating information to the school audiences, i.e., the children, their parents, and teachers? Will these channels or systems raise awareness among the school publics as to the existence of these policies, what they encompass and the consequences of noncompliance? A long distance course on strategic communications, which was developed by the World Bank Institute and the World Bank’s External Affairs with financial support from the Norwegian Education Trust Fund, will be offered in early-2001. The course teaches teams to build partnerships and to disseminate messages effectively. School health teams from West and Central Africa have taken the course to develop their school health program’s information, education, and communication (IEC) activities. Might this be beneficial to the school health program implementers?

B. Water and Sanitation in Schools

The school environment may damage the health and nutritional status of schoolchildren, particularly if it increases their exposure to hazards such as infectious disease carried by the water supply. Hygiene education is meaningless without clean water and adequate sanitation facilities. It is a realistic goal in most countries to ensure that all schools have access to clean water and sanitation. By providing these facilities, schools can reinforce the health and hygiene messages and act as examples to both students and the wider community. This in turn can produce a demand for similar facilities from the community. Sound construction policies will help ensure that facilities address issues such as gender access and privacy.

Studies have shown that girls’ attendance can be positively affected by the provision of appropriate sanitation facilities such as girls’ latrines that are closed, separated from, and more private than those for boys. Providing separate facilities for girls, particularly adolescent girls, contributes significantly to reducing dropout at menses and even before.

Sound maintenance policies will help ensure the continuing safe use of these facilities. Is there a system for preparation and maintenance of the water source and latrines? Are there schools with latrines and water points that are not being utilized by students? What prevents the children from using these installations? How involved are the communities, NGOs, PTAs, teachers, and other partners and donors in these activities? How can their inputs be maximized?

C. Skills-based Education

This approach to health, hygiene, and nutrition education focuses upon the development of knowledge, attitudes, values, and life skills needed to make and act on the most appropriate and positive health-related decisions. Health in this context extends beyond the physical to include psychosocial and environmental health issues. Changes in social and behavioral factors have given greater prominence to such health-related concerns as HIV/AIDS, early pregnancy, injuries, violence, tobacco, and substance use. Unhealthy social and behavioral factors not only influence lifestyles, health, and nutrition, but also hinder educational opportunities for a growing number of school-age children and adolescents.

Central to effective skills-based health education and a positive psychosocial environment is the development of attitudes that support gender equity and respect between girls

February 2002 and boys, such as dealing with peer pressure. When individuals have such skills, they are more likely to adopt and sustain a healthy lifestyle during schooling and for the rest of their lives.

Is there skills-based hygiene education that encourages children to use hygienic practices and sanitary facilities? There has been success in reducing the impact of HIV/AIDS in different parts of the world. In such cases, there is evidence of an effective skills-based education demonstrating that children have learned participation, decision making, negotiation, and self- assertion skills, which induce positive behavior change such as delayed sexual activity or use of condoms; these changes in turn have effectively reduced incidences of STDs, including HIV/AIDS. Are the lessons appropriate for the children and the teachers? Are they integrated into the curriculum? Have the teachers been properly trained to teach these lessons? Do the teachers have the necessary and appropriate teaching materials and resources? How are NGOs, PTAs, and communities involved? Can their involvement be increased? What are other partners and donors doing?

D. Health Services Delivered in Schools

Schools can effectively deliver some health and nutritional services provided that the services are simple, safe, and familiar and address problems that are prevalent and recognized as important within the community. If these criteria are met, then the community sees the teacher and school more positively and teachers perceive themselves as playing important roles.

Treatment for worms and schistosomiasis has been effective in increasing the attendance and learning of children in Tanzania. Research in Tanzania has proven that provision of iron supplements to combat anemia can impact children’s cognitive abilities. What other simple health interventions delivered in schools has been implemented in different parts of Tanzania? How are the different partners from the different ministries and segments of the communities involved in these activities? What are the roles and responsibilities of each? Are there any programs that have been successful at scaling up to national level? What are barriers and challenges to developing these programs at a countrywide level?

February 2002 Section 4. Project Appraisal Documents (PADs): Extracts from Project Appraisal Document (Annex 2) Describing the School Health and Nutrition Component

School health programs can be components of different types of social sector projects. The following are examples from Project Appraisal Documents (PADs) of a wide range of projects in the Human Development sector including HIV/AIDS prevention, Early Childhood Development, Nutrition, and Education. Only the descriptive part of Annex 2 dealing with the School Health and Nutrition subcomponent is included.

4.1 HIV/AIDS, Malaria, STDs, and Tuberculosis (HAMSET) Control Project in Eritrea

4.2 HIV/AIDS Control Project (MAP) in Uganda

4.3 Education Sector Expenditure Program in Mali

4.4 “Quality Education For All” Program in Senegal

4.5 Basic Education For All Program in Guinea

4.6 Basic Education Subsector Investment Program (BESSIP) in Zambia

4.7 Integrated Early Childhood Development (IECD) Project in Eritrea

4.8 Community Nutrition II Project in Madagascar

February 2002 4.1 HIV/AIDS, Malaria, STDs, and Tuberculosis (HAMSET) Control Project in ERITREA

(This text is abstracted from the section of this multi-sectoral project that will be implemented by the Ministry of Education.)

Promote Healthy Lifestyles through the Education System

This component aims to improve educational outcomes to promote good health and prevent the spread of HAMSET. The framework of the FRESH partnership (Focusing Resources on Effective School Health—WHO, UNESCO, UNICEF, and the World Bank) has been used to prioritize the most cost-effective actions, particularly for the poor and disadvantaged. The approach will be implemented through the Ministry of Education (MOE) school health program in both the formal and non-formal systems. The project will finance activities that aim to (i) strengthen skills in school health programming both centrally and regionally; (ii) promote healthy practices and behavior change in students and teachers; (iii) establish school-based support and health services; and (iv) promote healthy practices and behavior change in adults.

Promote skills in school health programming and monitoring by establishing a long- term link with an international network on school health (the Partnership for Child Development) in order to transfer international school health programming skills to managers within MOE. Over three years, MOE and Ministry of Health (MOH) staff will gain experience from other school health programs in regional countries and will acquire programming skills through short training fellowships. The component will conduct a situation analysis to lay the basis for the school health program. The project will provide electronic communications and two vehicles for the Project Management Division.

The component will establish long-term monitoring through the national network of 75- school inspector and 800 parent-teacher associations. Zoba-level and national workshops will provide an opportunity for sensitization, orientation, feedback, and program refinement. The project will arrange workshops for the 200 directors of secondary schools and the 600 directors of primary schools on the same frequency and schedule. Experience developed during the project will determine the level of dialogue that MOE will need to continue after the project to ensure sustainability of this monitoring system.

Promote healthy practices and behavior change in students and teachers by (i) reforming the curricula at primary (grades 4-5), Junior Secondary School (grades 8-9, 10-11), and teacher training levels and (ii) developing teacher manuals and supplementary surveys of knowledge, attitudes, practices, and prejudices among all five target populations and in designing, preparing, and testing the materials. The project will produce secondary school and teacher training materials in English for 3,000 teachers and 170,000 students. It will produce the basic education level materials in eight regional languages for 6,000 teachers and 85,000 students. MOE will undertake formative assessments and reprinting as necessary, closely coordinating mass media messages through the Communications Coordinating Committee established in subcomponent 2.1, on which MOE is represented.

The project will ensure that all existing teachers and teachers entering the education system in the future, will understand and support the curriculum. The project will support a sequence of training or trainer workshops already developed with UNICEF by regional countries as part of the FRESH partnership—to achieve universal coverage rapidly. At the secondary level, the workshops will train 200 trainers to reach 2,500 teachers by the end of the second year and at the primary level, 6,000 teachers before the end of the third project year. Staff of the Teacher

February 2002 Training Institute and faculty of education at the University of Asmara, who provide pre-service education for new teachers, will participate in intensive training in project years 1 and 2 and, thereafter, teach the life skills curriculum to all new teachers (currently about 600 primary and 50 secondary teachers per annum).

To reinforce healthy practices through a broad view of good health, the project will provide sanitation and basic garbage disposal for the 200 schools that are without adequate sanitation. (The IEDC project will provide facilities for the remaining 150 schools that lack proper sanitation.) The project will construct these facilities in cooperation with the PTAs; it will provide separate facilities for boys, girls, and teachers. Each school administration will develop routine cleaning procedures and the PTA will develop and agree with MOE a long-term maintenance program prior to construction beginning.

Establish school-based health services by establishing procedures for school-based counseling, testing alternatives to teachers for providing school based health services, and establishing school-based health clubs. The project will develop guidelines, workshops to introduce appropriate skills to teachers, and minor recurrent costs. MOH will assess and validate the effectiveness of mobile health teams versus teacher-based approaches for health delivery of simple, safe, and familiar services, for example, deworming, provision of micronutrient supplements, and encouraging treatment-seeking behavior for students with malaria symptoms. The community school representative on the Kebabi committee for community-managed HAMSET response to component 4 will be able to propose school-managed support as an alternative to be considered within the community resource envelope.

Promote healthy practices and behavioral change in adults by enhancing the MOE’s radio broadcasts of adult education courses. With a network of 800 facilitators, it is the largest non-formal program of the Ministry of Education. The project will design and test new HAMSET modules for facilitators and supplementary materials for participants, coordinating the content with the Communications Coordinating Committee. It will translate the materials into eight languages and publish a total of 60,000 copies. The 74 adult literacy coordinators will participate in a training-of-trainers workshop and then run a series of intensive 15-day workshops (two per Zoba) to train the facilitators in the use of the new manuals and supplementary materials.

February 2002 4.2 HIV/AIDS Control Project (MAP) in UGANDA

(This describes the component of the multisectoral project that will be implemented by the Ministry of Education and Sports.)

The interagency partnership (WHO, UNESCO, UNICEF, and the World Bank) for Focusing Resources on Effective School Health (FRESH) has identified a framework of the most cost-effective practices in promoting health through schools, including preventing HIV/AIDS. The approach described here conforms to this framework of effective health policies for the education sector, skills-based health education, and school-based health services.

The component aims to ensure that the education sector has clear and transparent policies on issues relevant to HIV/AIDS. These policies should include access to school of children and teachers affected by AIDS, sanction against sexual harassment and abuse by teachers, and grade- specific content of curriculum. In addition, it should communicate the policy to all pupils, teachers, and parents.

A. Review the primary and secondary education curriculum to introduce the following topics: (i) reproductive health, (ii) the prevention of HIV/AIDS and of sexually transmitted infections, and (iii) risks posed by alcohol abuse, female mutilation, defilement, and early marriage. The UAC will provide technical guidance for the development of the new curricula. The target population will be consulted during the process of curriculum development. Lessons will be developed which seek behavioral change through a teaching approach that targets skills rather than knowledge. These skills will be grade- and age-specific, but will include negotiation, resisting peer pressure, building self-esteem, communication, and assertion. The lessons will be developed through a facilitated “key trainer” workshop, which will also produce a cadre of trainers to transfer these lessons to teachers through district-level workshops. The lessons will be tested and developed into a teacher manual that will form the basis for the district-level training.

B. Develop and distribute the relevant training materials and train teachers and trainers on the prevention of HIV/AIDS and sexually transmitted infections at the national and district levels.

C. Promote youth HIV prevention programs, including condom distribution, in collaboration with the AIDS Commission and Ministry of Health.

D. Expand HIV/AIDS and sexually transmitted infections-related counseling and testing to schools, colleges, and institutions of higher education, using peers and parents as key resources.

E. Promote HIV/AIDS initiatives including those led by schools, student associations, and sport clubs, as well as community initiatives for the education and welfare of orphans (that is, “school check” schemes (both activities to be financed under Part C).

F. Monitor and evaluate the impact of HIV/AIDS prevention activities on the education sector, in collaboration with the Uganda AIDS commission. This activity will include systematic assessment and forecasting of the impact of AIDS on the education system, including the numbers of orphans of school age, the numbers of school-age children, and the numbers of teachers. The rate of recruitment and development of new

February 2002 teachers will be adjusted in response to these figures and educational targets. Remuneration of teachers will be monitored to determine the impact of competitive salaries from other sectors.

February 2002 4.3 Education Sector Expenditure Program in MALI

HIV/AIDS and the Role of Women. Particular attention will focus on two crosscutting issues: HIV/AIDS and the role of women. These issues were selected because of their profound implications for education in Mali and the education sector’s potential to affect the manner in which they are dealt with countrywide. They will be discussed, as appropriate, for each subcomponent.

HIV/AIDS. The prevalence rate of HIV/AIDS is relatively low in Mali, as compared to other African countries (4% of pregnant women, according to UNAIDS), but the disease is a growing epidemic that appears to disproportionately affect the education sector. Teachers may themselves constitute an important vector for spreading the disease. In neighboring Côte d’Ivoire, 70% of mortality among teachers is due to AIDS. Through the PRODEC, school facilities and education sector resources will be used to limit the spread of the epidemic. Approaches will include providing students and teachers with relevant information through sex and life skills education and culturally accepted materials that focus on sexually transmitted diseases and HIV/AIDS. Support will be given for an open dialogue and for behavior change interventions such as peer education, parent-child dialogue, discussions on changing harmful traditional practices (such as female genital cutting), condom promotion, prompt treatment of other STDs, and discussions aimed at destigmatizing the epidemic. Drama, songs, and role-playing adapted to the cultural context will personalize the messages.

School Health and Nutrition. Malnutrition and poor health among school-age students have been linked to lack of academic success and an increased likelihood that children will not complete the primary cycle. To change the pattern, this component will strive to develop a low- cost program of micronutrient supplements and deworming, focusing in particular on areas in which irrigation programs have greatly increased the incidence of such diseases as schistosomiasis.

The goal of the school health program in Mali is to improve students’ learning and achievement. In this context the Ministry of Education has made school health and nutrition an essential means of improving the quality of learning. This strategy includes four areas of intervention: (i) the health policy at the school level; (ii) procurement of water and sanitation; (iii) education for health; and (iv) nutrition and hygiene. These intervention areas are similar to the FRESH framework (a partnership between WHO, UNICEF, UNESCO, and the World Bank). The implementation of this strategy will require a close collaboration between the ministries of health and education and also the involvement of NGOs. In addition, the school health program will support local, regional, and national intervention programs, which also seek to prepare and organize education officials, teachers, communities, and local, regional, and national education institutions to be aware of social, economic, and demographic changes that will be encountered by parents, schools, and students. This subcomponent will be supported by the above donors and by the World Food Organization (PAM).

Thematic issues. Parent surveys often indicate that parents say that health concerns and sexual safety preventing them from sending daughters to school. This program will address these concerns directly. The program will also develop new partnerships to find culturally appropriate ways of providing life skills training in the context of the growing prevalence of diseases such as malaria and HIV/AIDS epidemic.

Phase 1: Development of deworming and micronutrient supplement programs. Training of school health teams, establishment of procurement protocols, etc. Development of age and culturally appropriate curriculum dealing with life skills and reproductive health issues. The

February 2002 program will also support provision of teaching materials and a training program in reproductive and life skills. Active collaboration with NGOs will be sought.

Phase 2: The deworming program will be taken to national scale; the program for reproductive health will be extended.

Phase 3: Follow-up to Phases 1 and 2, as appropriate.

February 2002 4.4 “Quality Education For All” Program in SENEGAL

Gender-specific Issues. Parents identify lack of latrines and distance from home to school as particular barriers to girls’ schooling. The access component is designed to respond to these issues. Girls also have far less access to learning than boys do—fewer textbooks, higher dropout rates, less attention from teachers. The quality component has been designed to address these problems through subcomponents dealing with grade repetition, textbooks, and teacher practices. Experimentation and analysis throughout Phase 1 will seek to identify gender-specific issues that may be addressed in subsequent phases. In addition, the use of local languages, being introduced in Senegal through this program, has also been reported in other countries (Mali, for instance). This move is intended to improve girls’ confidence and participation and to decrease their repetition rates. It can also be expected that overall improvements in reading skills will have their biggest impact on girls’ education, since their repetition rates exceed those of boys. Given the overall gender gap in literacy, the adult literacy program specifically targets females.

HIV/AIDS-specific Issues. Although the prevalence rate of HIV/AIDS is very low in Senegal compared to that of other countries in the region (1.7% according to UNAIDS), this disease is of great concern within the education sector and will receive close attention throughout the life of this program. Age disparities in sexual relationships appear to put adolescent girls at particular risk. Teachers may also be an important vector for spreading the disease. Through this program, educational institutions and resources will be used innovatively as tools to keep the epidemic from spreading. This will be accomplished in part by providing students with pertinent information on STDs and HIV/AIDS and in part through school programs that address the risks of unprotected practices and encourage open communication. All project components will be considered for their potential to address these issues.

Retrofitting of Primary Schools with Latrines and Wells, Rehabilitation, and Maintenance. Support will be provided under the project for retrofitting primary schools with latrines and wells and for renovation of deteriorating classrooms. Management of this program will be handled, as is new construction. Efficient maintenance programs will be established for all classrooms and equipment. In Phase 1, IDA, ADB, and AFD will support this subcomponent for the most part.

Phase 1: Under IDA financing, approximately 1,800 classrooms will be rehabilitated, covering about 60% of identified need; 570 schools will be retrofitted with wells representing 22% of identified need; and 1,080 schools will be retrofitted with latrines, representing 46% of identified need. Financed maintenance programs will be tested in three regions.

Phase 2: Rehabilitation of the remaining 1,200 deteriorating classrooms; retrofitting with latrines and wells consistent with identified needs and nationwide implementation of the maintenance system tested during the Phase 1.

Phase 3: Monitoring and improvement of the maintenance system.

Increase Student Learning Capacity through a School-based Health and Nutrition Program. Senegal has never had a preventive health program in its schools. There are, however, two strong reasons for developing such a program: (i) students in good health tend to have better attendance and achievement rates and (ii) health lessons learned in school can have a substantial impact on later health practices. The program will develop a health education component based on a culture- and age-appropriate life-skills curriculum. It will place particular emphasis on reproductive and sexual health, including FGM. Long-term impact is expected to be greatest for later health practices. This has been shown to be particularly true for women, who are typically

February 2002 responsible for most health decisions in families. This subcomponent will support pilot activities to promote such a program by focusing on health and nutrition interventions that are low cost and easy to deliver. In Phase 1, this subcomponent will be financed by IDA and will be paired with UNICEF activities in this area.

Phase 1: This phase will (i) establish appropriate institutional arrangements between the Ministries of Education and Health; (ii) create a school health database to identify the deficiencies/parasites for students by region; (iii) develop mechanisms for the micronutrient supplement and anti-worming program; (iv) prepare teaching materials and a family education program; (v) develop criteria, mechanisms, and evaluation tools for the pilot operation; (vi) choose a region in which to implement the pilot operation; (vii) implement the program in the test region; (viii) evaluate the results of the pilot operation and draw lessons for the following phase. Phase 1 will also see development of an anti-STD and HIV/AIDS campaign, with particular focus on adolescent girls.

Phase 2: Based on lessons from Phase 1, the program, the mechanisms, and the tools will be adapted for extending the program into the additional nine regions. There will be an analysis of the impact of the school health initiative on access and learning quality in the test region and the implication of these results will be extended to the other nine regions. There will be an adjustment of the teaching curriculum in these other regions to incorporate school health.

Phase 3: The family education program will be taken to scale, along with development of additional initiatives: malaria, tobacco, etc. There will be a study of the possibility of developing the school health module at the secondary school level for the follow-up 10-year program (after 2010).

February 2002 4.5 Basic Education For All Program in GUINEA

Retrofitting Primary Schools with Latrines and Wells/Renovation/Maintenance. This project will provide support for retrofitting primary schools with latrines and wells and for renovating existing classrooms. As with new construction, it is expected that NGOs will handle management of this program. Approximately 1,000 classrooms will be renovated in Phase 1. Schools will be retrofitted with wells and latrines. Funded maintenance programs will be established for all classrooms. The Emergency Fund for School Repairs established under PASE 2 will be maintained and extended.

Improving the Quality of Schooling

Gender-specific Issues. Currently, girls have far less access to learning than boys— fewer textbooks, higher dropout rates, and less attention from teachers. Subcomponents dealing with grade repetition, textbooks, and teacher practices have been designed to address these issues. Experimentation and analysis throughout Phase 1 will seek to identify gender-specific issues that may be addressed through the various quality subcomponents. The results of these studies will be used to improve the initiatives in Phases 2 and 3. For example, the use of local languages has been reported in other countries (Mali, for instance) to improve girls’ confidence and participation and to decrease their repetition rates. It can also be expected that overall improvements in reading skills should have their biggest impact on girls, since their repetition rates are currently much higher than those of boys.

School Health and Nutrition Program. Studies have shown that malnutrition and poor health in school-aged children are associated with low rates of achievement and persistence in schooling. A low-cost micronutrient supplement and deworming program has been developed in Guinea under PASE 2. This initiative will be extended under the BEFA program. Collaboration with the NASA Life Sciences unit will be explored as a way of improving targeting populations vulnerable to specific diseases or parasitic infection. Additional support will be provided for developing classroom teaching materials and a family education program that will include an anti-STD campaign. This program will extend the reach of the school health unit to the secondary and university levels. Collaborations will also be established with NGOs operating in the country. Pilot testing of initiatives to prevent and/or treat malaria will be conducted. Closer collaboration with ECD initiatives will help to include coverage of children aged 4 and lower.

Phase 1: This phase will see development of an anti-STD and anti-HIV/AIDS campaign, with particular focus on adolescent girls. It will also encompass extension of an existing micronutrient supplement and deworming initiative along with preparation of classroom teaching materials and a family education program. Family education will include a health education component based on a culture- and age-appropriate life-skills curriculum With particular emphasis given to reproductive and sexual health, including FGM. Long-term impact is expected to be greatest for later health practices; this has been shown to be particularly true for women, who are typically responsible for most health decisions in families. Increased involvement of NGOs is expected.

Phases 2 and 3: The family education program will be taken to scale, along with development of additional initiatives—malaria, tobacco, etc.

February 2002 4.6 Basic Education Subsector Investment Program (BESSIP) in ZAMBIA

Objectives: The overall objective is to promote healthy and well-nourished children, who have been provided with basic education and to improve their capacity to learn. Objectives for the period 1999-2001 are to develop a draft policy on school health and nutrition, conduct a baseline survey of Grades 1-7 pupils, and design and pilot task intervention models.

Description: The Ministry of Education will commission a baseline survey of nutritional deficiencies in primary school children and implement a pilot scheme in two districts in Lusaka and the Eastern Provinces to determine the feasibility and cost of a National School Health and Nutrition program. The baseline survey, which will build on studies conducted by the Ministry of Health (MOH), will utilize a small sample of children. The pilot scheme will test integrated interventions using four models for supporting food supplementation, micronutrient provision, and deworming. Of particular interest will be the mobilization of community support for some of the interventions.

Implementation: A Senior Inspector of Schools within the new Standards and Curriculum Directorate will have overall responsibility for implementing this subcomponent. A representative group, which will be appointed as a SHN oversight committee, will include delegates from of MOH and Central Board of Health, National Nutrition Commission, Directorate of Teacher Development, and PAGE. The pilot will be planned and implemented jointly with the Central and Districts Boards of Health.

February 2002 4.7 Integrated Early Childhood Development (IECD) Project in ERITREA

The main objective of the Integrated Early Childhood Development (IECD) Project is to promote the healthy growth and holistic development of children under age six, primary school children, and children in difficult circumstances. To this end, the project will provide services and support for young children’s basic needs: health care, nutrition, social protection, cognitive stimulation, affection, and early education. The program, designed to equip parents, mothers, caregivers, and the community with knowledge and services to support the young child’s growth and development, is targeted at various stages of his/her progress in the critical early years. Mothers and caregivers will be equipped to deal with childhood illnesses, improve existing nutrition behaviors, and understand the value of cognitive stimulation in the early years. A range of direct service approaches will include supplying health clinics to address the major childhood illnesses; using kindergartens to improve access to early childhood education; assisting orphans from the long civil conflict and AIDS and providing health services for children in the primary schools.

The nationwide program is expected to reach about 560,000 children aged 0-6 years, 310,000 primary school children and 32,000 orphans over a five-year project implementation period (2000-2005). Interventions will be divided into age-appropriate categories, that is, those targeted for the younger age group of 0-3 years and those aimed at the older age group of 4-6 years. While some interventions such as IECD are expected to cover about 560,000 young children, some activities are expected to cover subsets of these children; for example, kindergarten provision and non-formal early childhood education and care will target about 31,000 and 90,000 children, respectively. The orphan reunification program will target about 32,000 children and supplementary therapeutic feeding will target severely malnourished children.

Improving Early Childhood Education and Care

This component seeks to:

A. Improve the primary school health environment

B. Implement school health interventions, which the Ministry of Health (MOH) will manage in collaboration with the Ministry of Education (MOE). Key health messages will be included in the school curriculum as part of teacher and life- skills training. Trained health workers and technicians will regularly provide primary eye care; oral health; eye, ear, nose, and throat examinations; skin examinations and mental health care, when possible, in nearby health facilities.

C. Develop a school health and sanitation program. This subcomponent will address the hygiene and sanitation situation of children in about 30% rural primary schools and preschool centers by establishing deep pit latrines and garbage disposal areas in each school and center. Each school will establish a health and sanitation club to maximize the effective use and cleanliness of the latrines and address other hygiene and sanitation problems in schools. The health and sanitation clubs will be effective tools for influencing the children in preschool centers and the community. In connection with the primary health care system, trained staff from MOH will provide established, routine health check-ups of children in both preschool and lower primary-level schools. Potable water will be provided in schools. Supplementary feeding programs will be established in

February 2002 schools to improve the nutritional status of disadvantaged children will be reviewed.

February 2002 4.8 Community Nutrition II Project in MADAGASCAR

Description of the School Health Component

Objectives and Scope. The objective of the school nutrition program is to improve the nutritional status of enrolled primary school children (aged 6 to 14). Deworming will, however, benefit, in addition, both non-enrolled children in the same age group and preschool children aged 3 to 6. The program will be implemented in the same districts as those covered by the Community Nutrition Program, reaching 100% of the target groups in those districts. It will also be phased in gradually over the six provinces of the country and will be expected to cover 50% of the targeted groups nationwide in the last year of the project, i.e., around 1,079,000 enrolled primary school children and 1,535,000 non-enrolled children aged 3 to 14. Because a school nutrition program has never yet been implemented in Madagascar, the first year of the project will be entirely devoted to the elaboration of pedagogical and communications materials and the training of trainers. The program will start in primary schools at the beginning of the project’s second year, with a coverage rate over the project life evolving as follows: 0% the first year, 10% the second year, 20% the third year, 35% the fourth year, and 50% the fifth year.

The Directorate for Primary Education of the Ministry of Secondary and Basic Education (MINESEB) will execute the school nutrition program with the assistance of the project coordination units. It is expected that the program will be implemented in 6,663 public and private primary schools (half the total number of schools) at the end of the project, involving around 20,000 teachers. The project will provide funding to private schools to execute the program activities. This will be made possible through the signing of a Convention between the Government and private schools. Parents will be asked to pay an annual contribution in cash or in kind of FMG 500 per household to the school cooperative. The resources generated will serve as the beneficiaries’ contribution to the community fund. The commitment will be materialized in the signing of an agreement between the parents’ association, the school, and the project, or will form part of the contract-programs where they exist.

Description

The school nutrition program will include the following activities:

1. Iron/folate supplementation. Teachers will distribute iron/folate tablets (60 mg iron/250g folate) once a week to enrolled primary school children.

2. Provision of anthelmintic treatment. Once or twice a year (depending on the results of the prevalence survey), teachers will distribute tablets of Mebendazole or Albendazole to all children between 3 and 14 years, enrolled or not. The distribution will take place on fixed days, at the beginning of the school year, and eventually halfway through the school year, during which primary schools will have an “open house,” inviting all children and parents to come. It will be preceded by strong information and sensitization campaigns, which will be organized at national and regional levels.

3. Promotion of nutrition and hygiene. Primary school teachers will promote good nutrition and hygiene with children during regular classes and with parents during formal meetings and informal sessions. They will communicate a few, simple messages that will be related directly to the daily life of the children at school.

February 2002 Section 5. Examples of Logical Framework Tables (Logframes)

Here are two sample logframes for the school health component, which may not be needed for project documents, but are useful in the planning of the activities.

5.1 Logframe for Mauritania

5.2 Logframe for Chad

February 2002 5.1 Logframe for MAURITANIA

Mauritania: School Health Component of the Education Project Logical Framework (DRAFT)

Hierarchy of Objectives Performance Indicators Monitoring and Hypotheses Evaluation Sectoral Objective

Improve enrollment and learning.

Project Objective

Improve student learning through improved school health- all schools for all students.

Anticipated Results

1. Clearly defined and implemented health policies (hygiene and nutrition).

2. Students received health, sanitation, hygiene, and nutrition education in school.

3. Latrines (for teachers, boys, and girls) and safe water access in all schools.

4. In the required schools, the teachers treated all students for intestinal parasites, malaria, trachoma, and micronutrient deficiencies.

February 2002 Activities Phases

1. School Health Policy. 1.1 Statements of School Health Policy. 1.1 A day of School Health Policy Development prior to the Education Project Identification mission (July 17th). 1.2 Central and peripheral institutional system. 1.2 Develop statements of School Health Policy (July 20th, draft). 1.3 Agreements for MEN and MSAS. 1.3 Define central and peripheral institutional system (DRASS and DREF) (July 20th, draft). 1.4 Develop agreements for MEN and within MSAS (July 31, 2000, first project of the agreements, draft). 1.5 Participate in the long distance communication strategy course (October 4- November 8, World Bank Mission Residence).

2. Students received health, sanitation, hygiene, and nutrition education in school. 2.1 Develop modules. 2.1 Participate in the Guinea Health Education workshop, organized by UNICEF and the WB (August 9-25, 2000). 2.2 Strengthen teacher-training system in basic 2.2 Committee meeting to develop budget and action plan: September 1, 2000 (five- health. year pre-service and in-service training on HIV/AIDS). 2.3 Insure module inclusion in pre-service and in-service training of teachers.

3. School sanitation. 3.1 Separate latrines for teachers, boys, and 3.1 Situation analysis of geographical distribution of parasites, diseases, and micro- girls. nutrient deficiencies in schools and of the water and sanitation status ((TDR+ checklist –July 15th; consultant has been hired—August 15th; provisional report –September 15th).

3.2 Train the PAs in latrine maintenance 3.2 Sub-regional workshop on water and sanitation (Abidjan, September 4-8). 3.3 Insure safe water access in all schools 3.3 Committee meeting to develop budget and action plan September 30, 2000.

4. School Health and Nutrition Services. In the required schools, the teachers treated all 4.1 Sub-regional workshop on Health Services system for Senegal, Mauritania, and students for intestinal parasites, trachoma, Mali/sub-regional in November—place and dates to be determined. malaria, and micronutrient deficiencies. 4.2 Committee meeting to elaborate budget and action plan—December 15, 2000.

School health action plan and budget—January 2001.

February 2002 5.2 Logframe for CHAD

Chad: School Health Component of the Education Project Logical Framework

Hierarchy of Objectives Performance Indicators Monitoring and Hypotheses Evaluation Sectoral Objective ____ School Performance Rate Improve learning achievement of the poorest students through ____ Enrollment Rate better health. ____ Male to Female Ratio

Project Objectives ____ Attendance Rate Improve attendance, participation, and learning capacity of the ____ Participation Rate poorest students through better health and nutrition via school ____ Degree of learning achievement based health services. Anticipated Results

1. Clearly defined health and nutrition measures applied at 1. The Ministry of Education adopts and spreads school the level of the Ministry of Education (MEN). health policies.

2. Provision of safe water and sanitation in the schools. 2. X% of existing schools are equipped with functioning latrines (3) and all new schools are equipped with 3. Students received health, sanitation, hygiene, and functioning latrines. nutrition education at school. X% of schools has access to safe water. X% of Parent Associations (PAs) is responsible for the 4. Communities are mobilized and sensitized on school maintenance of the latrines. health. 3. X% of trainers is trained. 5. Poor students received school health and nutrition X% of teachers is trained. services.

February 2002 4. Most members of the community participate in the school health project.

5.1 The prevalence of infections and nutrition deficiencies among students is decreased: Intestinal parasites by X% Urinary bilharziosis by X% Iodine deficiency by X % Vitamin A deficiency by X% Iron deficiency by X%

5.2 X% of students suffering from fevers have received malaria medication 5.3 X% of schools has a PA managed community cafeteria.

February 2002 Activities Phases Document Points

1. School Health policies 1.1 Develop a formal document for MEN 1.1 Finalize the agreement protocol 1. Develop a description of the 1.2 Develop a document for general use 1.2 Analyze the school health policy status educational objectives of 1.3 Spread school health policies 1.3 Develop both documents school health 1.4 Evaluate the activities with all the players 1.5 Participate to the long distance communication 2. Define measures against strategy course STDs/AIDS 1.6 Prepare a strategy to spread and implement school Early pregnancies health policies Tobacco and alcohol addictions 2. Provision of school sanitation and safe water 2.1 Evaluate the water and sanitation situation Latrines (Teacher- girls- boys 2.1 Identify the appropriate type of latrines for existing (inventory of premises) and maintenance) and new schools 2.2 Meet with the PAs to discuss maintenance Water 2.2 Equip X% of existing schools and all new schools 2.3 Identify all players and organize a workshop to School based health services with latrines define the needs (TDR) Sexual harassment 2.3 Train the PAs in latrine maintenance 2.4 Sub-regional workshop on school sanitation Harmful practices (excision, 2.4 Identify types of water supply 2.5 Committee meeting to elaborate budget and action early marriages) 2.5 Insure access to safe water in all schools plan 3. Define school health implementation strategy

3. Students received skills-based health, sanitation and 3.1 Meetings: DBE (Directorate of Basic Education), hygiene, and nutrition education DTEA (Directorate of Training and Educational 3.1 Develop modules Action), World Bank consultants for training and 3.2 Validate modules editorial policies. 3.3 Organize workshops for the 65 supervisors /main 3.2 Workshop visit for Health Education in Guinea trainers organized by UNICEF and the World Bank. 3.4 Train the 360 educators 3.3 Committee meeting to elaborate budget and action 3.5 Train the 3,800 teachers and 4,000 community plan teachers 3.6 Insure that the modules are included in the initial training

February 2002 4. Communities are mobilized and sensitized to school 4.1 Participate in the long-distance communication health strategy course. 4.2 Create a communication strategy (included: budget and action plan).

5. Poor students received school health and nutrition 5.1 Study on the geographical distribution of parasites services and micro-nutrient deficiencies in the schools 5.1 In the required schools, the teachers treated all 5.2 Sub-regional workshop on health services, students for intestinal parasites, bilharziasis, and organized by WHO micronutrient deficiencies in Vitamin A and iodine once 5.3 Committee meeting to elaborate budget and action or twice a year plan 5.2 In the required schools, the teachers treated all students with iron/folate supplement once a week for 6 consecutive weeks 5.3 The teachers have distributed malaria medication to all students with a fever 5.4 The schools are equipped with a community cafeteria managed by the Pas

February 2002 Section 6. Examples of Letter of Understanding (LOU) between the Ministry of Education and the Ministry of Health on School Health and Nutrition

Here are two examples of LOUs from Zambia and Senegal. The success of a school health program demands a written statement between the Ministry of Education and the Ministry of Health clearly identifying the respective responsibilities for an effective intersectoral partnership.

February 2002 6.1 Example Letter of Understanding (LOU): ZAMBIA

LETTER OF UNDERSTANDING BETWEEN THE MINISTRY OF EDUCATION AND THE MINISTRY OF HEALTH ON SCHOOL HEALTH AND NUTRITION

1.0 PREAMBLE: The Ministries of Education and Health are committed to reviving School Health and Nutrition services for the benefit of school going children aged between 0 and 18 years old.

Whereas: The Government of Zambia (GRZ) is committed to improving the social status of its nationals through economic and public sector reforms. The Ministry of Education (MOE) is implementing Basic Education Sub-Sector Investment Program (BESSIP) as a national education program. The main objectives of BESSIP are increasing enrollment and improving learning achievements. Under BESSIP there are seven components contributing to the achievement of these two objectives.

These are:

 Infrastructure  Teacher Development, Deployment, and Compensation  Education Materials  Equity and Gender  School Health and Nutrition  Curriculum Development  Capacity Building and Decentralization

In its 1996 Education Policy Document, “Educating Our Future: National policy on Education,” the goal for education provision is to provide quality education to all Zambian children;

Whereas: At independence in 1964, the Ministry of Health (MOH) provided comprehensive School Health and Nutrition (SHN) services including physical examination, referral and treatment of ailments when necessary, inspection of immunization scars (e.g., Bacillus Calmette Guanine (BCG)), and micronutrient supplementation through food supplements, mainly milk and buns. In 1978 the MOH deployed public health nurses in many districts to strengthen maternal and child health as well as school health services;

Whereas: In 1985, the MOE adopted the Child-to-Child Program as a tool that gives health information directly to school-going children and through them, indirectly, to the community. The MOE also reintroduced production units in schools to enable children to learn about food production as well as the benefit from the products of their work. The impact of these programs has been mixed. Some schools seemed to be doing well while rural schools benefited little from the two programs. Teachers previously provided support of good sanitation and hygienic practices of children through regular checks, but currently, this is infrequent.

Whereas: In the last two decades, SHN services have declined in terms of access, availability, and quality. Rarely are school children physically examined, referred, and treated.

February 2002 Food supplementation ceased in the early 1970s due partly to an insufficient understanding and appreciation of the role that health and nutrition contributes to learning achievement. This decline has been exacerbated by a misconception that SHN is the prerogative of MOH alone rather than being regarded as a multisectoral development issue;

Generally, the health and nutrition status of school children has continued to deteriorate;

2.0 PROBLEM STATEMENT:

Whereas: The problems that school children face as they go to school are many and varied. The integrated school curriculum together with the teaching and learning materials do not adequately address the quality and relevance of health and nutrition issues for behavior formation and change of individuals. Pupils are often placed in a poor physical environment as infrastructure in a significant number of schools has deteriorated through heavy use and lack of maintenance. Furniture is often in a bad state of repair or is absent. In addition, lack of a school health and nutrition policy, harmful traditional practices, and poor sources of water and sanitation compound this problem;

Whereas: As a result of food insecurity and high levels of poverty in the country, malnutrition has increased among school children as manifested by Protein Energy Malnutrition (PEM) and micronutrient deficiencies. The most common micronutrient deficiencies are Vitamin A, Iron, and Iodine. According to the Demographic Health Survey (DHS) (1997), malnutrition contributes to over 50% of all infant and child deaths in Zambia. A recent study (Luo et al. 1999) found that out of 1,427 children screened, 14.5% were severely anemic, and 22.2% had malaria parasitaemia. It was also stated that iodine deficiency ranges between 50% and 80% of the general population and Vitamin A deficiency is endemic in most children;

Whereas: Malnutrition levels are worsened in school children by the increase in parasitic infestations due to unsafe drinking water and poor sanitation. Parasitic infections in children can result in diarrhea, anorexia, and general malaise. When children are heavily burdened with worms, they eat even less when food is available and their absorption and retention of certain nutrients is impaired. Consequently, this diminishes children’s learning capacity and their ability to pay attention and to concentrate. Growth and cognitive development also diminish;

Whereas: Environmental-related diseases such as malaria, cholera, and dysentery are also widespread in school communities. These pose a challenge for environmental health and hygiene in relation to clean, safe drinking water and good sanitation practices;

Whereas: The current HIV/AIDS situation adds to the complexity of health issues in education. Although the rate of HIV/AIDS among school children is low compared to those of adults, girl children suffer disproportionately as victims. Increasingly, induced abortions and alcohol and drug abuse have been common;

Whereas: The impact of HIV/AIDS is devastating to children and touches all aspects of their lives. Specifically, children will experience psychosocial distress, increased malnutrition, loss of health care including immunization, fewer opportunities for schooling and education, exposure to HIV infection, homelessness, starvation, and

February 2002 crime. A further dimension of the HIV/AIDS problem is the fact that teachers fall within the age groups that is most vulnerable to infection;

Whereas: Children suffer from health, communicable, and nutritional problems due to micronutritional deficiencies, unsafe water supply, and poor sanitary conditions. This has been accentuated by the lack of SHN policy, strategies, and regulations not only to ensure good nutrition in school children, but also to reinforce the need for good sanitary environments;

Whereas: A health and nutrition program supported by policy and strategies is critical in improving not only the health and nutrition of school children, but also to enhance academic achievement and acquisition of life skills.

The parties now therefore agree as follows:

CLAUSE ONE

OBJECTIVES:

Parties agree that the objectives of this LOU are to:

I. Improve collaboration between the two ministries.

II. Revamp SHN activities

III. Guide the implementation of the program using the LOU

IV. Clarify the roles of the MoE and MoH/CboH in the implementation of SHN strategies

CLAUSE TWO

IMPLEMENTATION:

 The parties agree that the Management Implementation Team (MIT) in the MOE shall work under the supervision of a program coordinating committee. The committee shall work under the guidance of the Joint Steering Committee (JSC), which is composed of representatives from MOE, MOH, and cooperating partners.

 MOE/School Health and Nutrition Component of BESSIP and MOH/CboH shall jointly implement the provision of integrated health and nutrition interventions.

 The administration of the interventions will commence in January 2001 in 80 (40 intervention and 40 control) pilot schools. Gradually, the interventions will be expanded to other schools throughout the country.

 This LOU will be effective from the date of signing but subject to the continual search for improved partnerships, information flows, and mutual trust.

February 2002 CLAUSE THREE

COLLABORATION:

The Parties agree that:

a) The Ministry of Education shall strengthen its links with MOH by addressing health and nutrition problems to improve the education, health, and nutrition outcomes of school children. Collaborations shall be linked through structures existing at each level as follows:

(i) Central Level: MOE/SHN Focal Point will provide policy direction of the program in liaison with CBoH/Health Promotions Specialist (Public Health and Research).

(ii) Provincial Level: The SHN team at provincial level will be responsible for policy translation and implementation. The MOE/SHN Provincial Focal Point shall be liaising with the CboB Provincial Director of Health.

(iii) District Level: MOE/SHN Focal Point in liaison with the District Director of Health will be responsible for program implementation.

(iv) School Level:  The classroom teachers and SHN Focal Point at school level will be responsible for program implementation in liaison with health workers from health centers in the catchment area.  Class teachers shall always inspect personal hygiene of children before starting any lessons.  Class teachers shall be administering deworming drugs, micronutrient supplements, and the cognitive assessment instrument.  Class teachers shall maintain health record cards:

a) The Ministry of Health shall strengthen links with the Ministry of Education to achieve School Health and Nutrition outcomes through the Central Board of Health and its structures throughout the National Health system as follows.

(i) Central Level: The School Health and Nutrition Program shall be a core-shared responsibility between the Ministry of Education and Health. The Health Promotion Specialist, under the guidance of the Director Public Health and Research in the Central Board of Health, will provide policy direction of the program on behalf of the MOH/CBoH in liaison with relevant Specialist in the program area such as pharmacy, Child Health, and Adolescent Health Specialist.

February 2002 (ii) Provincial Level: The School Health Promotion Team at provincial level will work closely with MOE Provincial SHN Focal Point to plan, implement, and coordinate school health promotion and education programs in the province. The Provincial Director of Health or delegated officer shall be liaising with the MOE Provincial SHN Focal Point on all SHN activities.

(iii) District Level: The School Health Promotion Team at district level through the District Director of Health or a delegated officer will collaborate with the MOE district SHN Team to plan and implement district wide School Health and Nutrition services.

(iv) Community Level: Health Center staff shall work together and be responsible for program implementation in liaison with SHN focal points at school level. Local health staff will visit schools in the catchment area to conduct physical examination, supervise the deworming and micronutrient administration days, provide basic treatment and for referral of sick pupils, conduct immunization, and support school health education

Ministry of Health and Central Board of Health will be involved in training and monitoring teachers on administration of drugs and other health activities.

CLAUSE FOUR

DRUG ADMINISTRATION:

The parties agree that:

 The drug to be used for Helminthes infections (Parasitic Worm Infections) shall be Albendazole/Mebendazole and Praziquentel. Albendazole/Mebendazole shall be administered to all children in the intervention pilot schools twice in a year. Praziquentel shall be administered only to the children who are infected with bilharzia worms.

 All the children in intervention schools shall be administered Vitamin A capsules twice a year and Iron tablets as appropriate.

 Classroom teachers will conduct assessments and screenings of all children before administration of drugs.

 SHN drugs will be handled as all other drugs (i.e., delivered to Medical Stores LTD for proper storage and performance of quality control procedures before distribution). The drugs will then be distributed to various District Stores from where they will be repackaged and issued to respective schools. The District Health Officers will supervise the administration of the drugs to pupils.

February 2002  Payment of local clearing and management fees to be incurred at Medical Stores LTD will be covered by MOE.

 CBoH will develop guidelines on repackaging and handling of SHN drugs by the District Health office in collaboration with MOE.

CLAUSE FIVE

RESPONSIBILITIES OF MOE AND MOH:

Parties agree that the MOE shall:

 In collaboration with MOH supervise planning, implementation, monitoring, and evaluation of all SHN activities and ensure that all activities support SHN program goals and are approved by the Intersectoral Steering Committee.

 Provide funding of SHN activities as described in the SHN component action plan.

 Prepare program implementation plans and annual work plans.

 Establish SHN/MIS at national, provincial, district, and school levels.

 Coordinate, monitor, and evaluate activities using agreed MOE and CBoH indicators.

 Disseminate guidelines for various interventions under SHN.

 MOE shall provide policy direction and coordination of SHN activities in BESSIP.

The MOH shall:

 Fund activities contributing to health outcomes such as immunizations.

 Provide technical support on the implementation of core health and nutrition activities including procurement of drugs, physical examination (screening), immunization, referral, and treatment of ailments.

 Ensure that the Public Health Act and other relevant health regulations are enforced.

 MOH shall provide policy direction and coordination of activities in CboH, DHMT, and health centers.

 In collaboration with MOE participate in planning, implementation, monitoring, and evaluation of all SHN activities

February 2002 CLAUSE SIX

REPORTING SYSTEM AND FORMAT:

Parties agree that the reporting system and format shall be as follows:

 Each class teacher shall maintain a health card for each individual child in his or her class. This will also include records of referral cases to health centers and counseling of any social, psychological, or economic problems.

 Health workers from health centers shall keep records of all referrals and treatment.

 MOH at central level, in collaboration with MOE, shall procure, distribute, and store all the drugs until such time they are needed at the schools.

 The DEOs shall keep all Health and Nutrition records in their districts for their own use and for use by other stakeholders.

 The DEOs shall submit regular reports to the MOE Management Implementation Team.

 Head teachers and class teachers shall monitor attendance, health and nutrition status, and general educational performance.

 Other stakeholders from central, provincial, and district levels from both MOE and MOH shall be involved in the monitoring of the program.

 An independent team shall be constituted to evaluate the impact of the program.

CLAUSE SEVEN

AMENDMENTS:

Parties agree that the amendments of this LOU shall be by mutual agreement at a round table. These shall immediately become effective upon signing the amended LOU.

SIGNED BY: SIGNED BY: Permanent Secretary Permanent Secretary MINISTRY OF EDUCATION MINISTRY OF HEALTH

DATE: DATE:

WITNESSED BY: WITNESSED BY: Chief Inspector of Schools Director General MINISTRY OF EDUCATION CENTRAL BOARD OF HEALTH

DATE: DATE:

February 2002 6.2 Example Letter of Understanding: SENEGAL

DECENNIAL PROGRAM FOR EDUCATION AND TRAINING (DPET) QUALITY EDUCATION FOR ALL PROJECT SCHOOL HEALTH COMPONENT

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AGREEMENT PROTOCOL BETWEEN THE MINISTRY OF EDUCATION (MOE) AND THE MINISTRY OF HEALTH (MOH)

I/- PREAMBLE

The objective of the “Quality Education For All” Project of the Ministry of Education is to develop access to quality basic education for all school age children in Senegal, thus giving the poorest and the most disadvantaged, in particular the girls, the possibility to go to school. One of the primary goals of the MOE is that the children are healthy and are able to learn in school.

The objective of the School Health Program of the Ministry of Education is to improve the learning capacity of the students through better health and nutrition. The Program will use the existing school based system resources, namely the schools and the teachers since they constitute the most efficient method of reaching the students. This strategy exemplifies an approach to school health, which was approved in an agreement among WHO, UNICEF, UNESCO, and the World Bank.

The main activities of this program are defined as follows:

1. Ensure sound school health policies;

2. Ensure safe water access and sanitation in all schools;

3. Provide basic skills-based health education; and

4. Develop a package of school health services which can be administered by the teachers under the supervision of health agents. These services will initially include treatment against malaria and intestinal parasites and micronutrient supplementation.

For effective improvement of the health and nutrition status of the school children, a good collaboration between the Ministries of Health and Education is necessary. The involvement of social partners is strongly encouraged (Parent Associations, NGOs, local community groups). This document aims at assigning tasks and responsibilities between the Ministries of Health and Education. It is, therefore, a step forward for this project.

February 2002 II/- DISTRIBUTION OF MISSIONS AND RESPONSIBILITIES

II.1. Ministry of Education tasks:

1. The Ministry of Education is responsible for all aspects of the implementation of the package of health services in the schools, namely:

 Planning of school activities

 Implementation

 Supervision

 Monitoring

 Teacher and student training

 Activity reports

 Financial management

 Resource mobilization

 Coordination of all school based activities

2. The National Pharmacy (PNA) will be responsible for the purchase, quality control, and distribution of medications, micronutrients, and miscellaneous medical materials required for the Project by the MOE to the Regional Pharmacies (PRA).

3. The Ministry of Education will sign a contract with the PNA with regards to the items mentioned in 2. above. The Ministry of Education will report to the Ministry of Health upon completion of the first three years of program implementation.

4. The MOE is responsible for the management of medications and supplements in the district depots and their subsequent distribution to the schools.

The school principal is responsible for:

 Storage of project supplied materials

 Supervision of the distribution in collaboration with the health agent.

5. The MOE is responsible for the revision of the school curriculum in order to include all aspects of School Health Education and stress life skills.

The MOE is responsible for the revision of school health and nutrition policies.

6. The MOE is responsible for the development and implementation of a training program in the New Curriculum.

February 2002 7. The MOE will restudy the status of the School Medical Inspector within the framework of the new Health Program and will make specific and appropriate recommendations in terms of coverage and cost.

8. The MOE, jointly with the Ministry of Health, will organize a training workshop on the strategy of the use of geographical data systems for the School Health Program activities planning.

II.2. Ministry of Health tasks

1. The Ministry of Health is responsible for the health of the population including that of the students.

The specific responsibilities of the School Health Program include:

 The technical content of the health messages

 An appropriate and useful protocol for basic school health services, quality control of health services and all treatment aspects of health services.

2. The Senegalese National Service of Food and Nutrition (SNAN), a division of the Ministry of Health, will assume the specific technical responsibility of the supervision and monitoring of nutrition activities, including micronutrient interventions. The SNAN will naturally be responsible for all nutritional aspects of school health programs.

3. The Ministry of Health will be responsible for the collection and transport of medications and school health related materials from the PNA to the PRAs and to the district depots. The District Chief Physician will supply the school principals with the medications and materials under the supervision and the approval of the MOE’s Departmental Inspector.

4. The MOH is responsible for all treatment activities in accordance with the national health care policies. This responsibility includes side effects derived from the use of the medications in schools.

5. The MOH will assist the MOE to identify the health and nutrition technical content of the messages and will insure that these messages conform to the national health policies.

6. The MOH will assist the MOE in the development of protocols for de-worming treatment and micronutrient supplementation.

NGOs, associations, and local community groups working with the two Ministries must play an important role to facilitate the establishment of school health activities in terms of health services and education. These organizations and institutions will be involved with teacher training but not with in-school implementation, a task reserved for the school teachers.

February 2002

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