TRANSACTIONS OFTHE ROYAL SOCIETY OFTROPICAL MEDICINE AND HYGIENE (1997) 91, l-2

(Leading

Better health, nutrition and education for the school-aged child

The Partnership for Child Development* Scientific Co-ordinating Centre, Wellcome Trust Centre for the Epidemi- ology of Infectious Disease, University of Oxford, Oxford, OX1 SPS, UK

Today, there are more children of school age and a greater proportion of children attending school than ever before in human history. This reflects the success of child survival programmes-UNICEF (1996a) esti- mates that more than 90% of the world’s children now survive beyond 5 years of age-and the increasing im- plementation by governments of compulsory universal basic education policies. These remarkable successes have created new challenges. The increasing numbers of survivors continue to face health and developmental problems, and their ability to attend school, and to learn while there, is often compromised by ill health. Contin- uing good health at school age would seem to be essen- tial if children are to sustain the advantages of a healthy early childhood and take full advantage of what may be their only opportunity for formal learning.

In considering ways to improve the health of school- children, the major focus has been on the potential use of the education sector itself for health delivery (HAL- LORAN et al., 1989; WHO, 1992). In many developing societies there are more teachers than health workers and more schools than clinics; the education sector pro- vides an already developed and supported infrastructure which might usefully supplement the existing primary health care system. Theoretical analyses suggest that school-based -health systems might rank amongst the most cost-effective of nublic health strategies WORLD BANK, 1993). To de&mine whether the& predictions are supported by practical experiences, a consortium of government, donor and technical agencies is working together as the Partnership for Child Development to conduct operations research into the processes, costs and benefits of health interventions delivered by the ba- sic education sector (BERRLEY & JAMISON, 1990).

An important first step in exploring these issues is de- fining what is meant bv a school-age child. since this will help determine appropriate interv&tions: The sex ratio of schoolchildren is dynamic with age, and changes markedly over the basic education transition from pri- mary to junior secondary school. This change occurs in paradoxical ways in different localities: in Africa the transition is associated with female drop-out, while in Latin America it is largely male. The age characteristics of a school-age child are also largely counter-intuitive. In much of Africa, enrolment occurs several years after the expected age so that, in one area of Tanzania for example, adolescents (defined by the World Health Or- ganization (WHO) as lo-18 years of age) make up 40% of children in grade 1 of primary school, and the entire complement of classes above grade 4 (TANZANIA PART- NERSHIP FOR CHILD DEVELOPMENT, 1996). Similarlv, a study in Ghana indicated that a significant majori-& (70%) of adolescents who attend school at all. attend primary rather than junior secondary school (GHANA PARTNERSHIP FOR CHILD DEVELOPMENT, 1996). This

*The principal investigators for these activities are: Professor Don Bundy (Co-ordinator), Dr Andrew Hall (Field Pro- gramme Co-ordinator), Dr Sam Adjei (Co-ordinator, Ghana Partnership for Child Development), Professor Charles Kiha- mia (Co-ordinator, UKUMTA, Tanzania), Professor Tara Gopaldas (Co-ordinator, MDMP, India), Dr Satoto (Co-ordi- nator, MITRA, Indonesia), Professor Ha Huy Khoi (Co-ordina- tor,Viet Nam Partnership for Child Development).

Correspondence should be addressed to Professor Bundy.

suggests that health education messages targeted at issues of special relevance for adolescents (e.g., human immunodeficiency virus/acquired immune deficiency syndrome, substance abuse, family planning and vio- lence) might appropriately be directed at some segments of the primary school population, who are deliberately excluded from such messages at present. These findings also emphasize the need for Iocality specificity in design- ing school health programmes, since there is considera- ble heterogeneity in the age and sex distribution, and therefore health priorities, of the school-age child.

There has been a tendency to view school-age chil- dren as essentially healthy because they suffer the lowest mortality of any age group. Yet their morbidity has rare- ly been studied and recent efforts to assess age-specific morbidity more carefully (WORLD BANK, 1993) have used extrapolations from other age groups and methods which contribute to underestimating morbidity in chil- dren over 5 years of age (BUNDY & GUYATT, 1996). When asked, schoolchildren themselves have a rather poor perception of their health status; surveys in Ghana and Tanzania showed that over 90% of responding chil- dren reported some symptoms during the 2 weeks pre- ceding the survey, and 42-52% reported conditions giving cause for concern (such as malaria and haematu- ria). Biomedical surveys of 8-12 years old children in Ghana, Tanzania, India, Viet Nam and Indonesia con- firmed that some significant health conditions were very prevalent among schoolchildren: 50-7 1% show stunt- ing (>2 SD below the reference height-for-age), 47-8 1% were anaemic (haemoglobin ~120 g/L), 23-96% had parasitic helminth infection. Furthermore, improved in- formation about specific diseases suggests that some conditions, which are focused primarily on younger age groups, such as malaria, may have importance for school-age children, as is also true for conditions tradi- tionally thought to be more important in older children, such as female reproductive tract infections (BRABIN et al., 1995). All this suggests that the perception of the health of schoolchildren requires some revision. It also indicates that the prevalent health problems of school- children are often locality-specific, but there are some problems which are ubiquitous.

The aim of improving health may alone be sufficient cause for health intervention in schoolchildren, but this need is greatly enhanced because good health is impor- tant for education (POLLLTF, 1990). Governments al- ready invest in providing schools, teachers and educational materials. These investments are compro- mised if schoolchildren are more frequently absent from school, or less able to learn while there, because of ill health. Associations with underachievement in school, or low scores in tests of congnitive ability, have been shown for such prevalent and ubiquitous conditions as short-term hunger, iron deficiency, iodine deficiency, and parasitic helminth infection (GRANTHAM-MCGRE- GOR, 1990; STERNBERG et al., in press). Primary pre- vention of these conditions would be the best course, but there is also an increasing body of evidence that in- tervention at school age can reverse some of the ill ef- fects. It is also apparent that government investments in early child development strategies, which aim to make a pre-school child healthier and more ready to learn in school (YOUNG, 1995), need to be followed by pro-

THE PARTNERSHIP FOR CHILD DEVELOPMENT 2

grammes that sustain health during the learning years. The success of child survival programmes does not

mean that they can now be replaced by child develop- ment approaches: survival remains the priority. Any new development strategy must therefore not only be cost-effective but also extremely low in absolute re- source requirements. The school system has been iden- tified as fulfilling these criteria (WORLD BANK, 1993), but there have been concerns that the education systems and teachers in developing societies are already too stretched to take on additional tasks, and that teachers and the community would resent the education sector playing a role in health. Carefully monitored school- based health and nutrition programmes in Ghana, Tan- zania, India and Indonesia have now shown that the education sector is capable of delivering a simple health package (health education, anthelmintics, sometimes with micronutrients) to large numbers of school chil- dren (50000 to 3 million) without the creation of specif- ic infrastructures. Furthermore, they have shown that teachers perceive this role in health as an acceptable, even welcome, extension of their overall role in the community, and that both students and parents concur with this view. These experiences suggest that the school system can contribute to health delivery provided that the package is simple, demands little school time, and is perceived as appropriate to local needs.

Analyses of costs tend to confirm the prediction that such education sector delivery methods are associated with small financial cost. Cost analyses of the Ghana programme compared 2 interventions with different de- livery requirements: mass delivery of a standard dose for all children (albendazole for intestinal worms) and de- livery, targeted at high-risk schools and individuals, of a dose adjusted for each subject (praziquantel for Schisto- soma haematobium infection, targeted by reported hae- maturia, dose calculated by teachers). In both cases the cost of the drug dominated the financial delivery costs (97% for albendazole, 68% for praziquantel), but the fi- nancial cost of delivering the more complex intervention was nearly 10 times greater. This suggested that the ed- ucation sector can indeed provide a delivery system re- quiring few additional resources, but that the cost of delivery increases with the complexity of the health package. The results also indicated that overall financial costs can be low. For the Ghana programme (85000 children), the delivered cost of albendazole was US$ 0.16 per child per annum, and of targeted, dose-adjust- ed praziquantel it was US$O.74 (GHANA PARTNERSHIP FOR CHILD DEVELOPMENT, 1996). For the India pro- gramme in Gujarat (2.83 million children), the cost of locally purchased ferrous sulphate, albendazole and vi- tamin A, delivered as a standard dose twice a year, was USSO. per child (GOPALDAS, 1996).

School-based delivery systems raise the concern that they fail to benefit children who are not enrolled in school, but who may be the most in need. Indeed, it has been suggested that they could exacerbate existing ineq- uities, f&example by nbt reaching absentee girls &fec:fect- ed with schistosomiasis in EgVDt (HUSEIN et al.. 1996‘1 and non-enrolled working boys infected with the same parasite in Ghana (FENTIMAN, 1995). On the other hand, experience suggests that ‘school health days’ may draw in non-enrolled children to receive treatments, even in countries with very low levels of enrolment such as Guinea (DEL ROSSO & MAREK, 1996). It has also been suggested that, in the absence of functional health programmes for school-aged children, school-based programmes at least offer the potential to reach signifi- cant numbers of this population.

The operations research of the Partnership for Child Development continues (HALYL et al., 1996). The results to date strongly suggest a need for programmes to im- prove the health of schoolchildren, both. because the children suffer from ill health and because better health leads to better educational outcomes. The results also

indicate that the education sector itself can offer a prac- tical and affordable means of meeting this need. An im- portant general conclusion is that the acceptability to teachers and affordability of the approach both diminish in proportion to the complexity of the health package. The optimal health package has yet to be defined. It will be locality-specific, but is likely to include some combi- nation of health education, health and nutrition servic- es, a healthy school environment, and appropriate policies for the rights of schoolchildren (UNICEF, 1996b). Whatever the approach, an investment in the health and education of the next generation may well be one of the most profitable that a society can make.

Acknowledgements The Partnership for Child Development programmes and

activities are supported by UNDP, WHO, the British Overseas Development Administration, UNICEF, the World Bank, the Edna McConnell Clark, Rockefeller and James S. McDonnell Foundations, and the Wellcome Trust.

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