Helminth Infections

Between 25 and 35 percent of school-age children are estimated to be infected with one or more of the major species of worms (Bundy 1997; see also chapter 24). The most common and important infections are caused by geohelminths (the roundworm Ascaris, the whipworm Trichuris, and the two species of hookworms Ancylostoma and Necator) and by the schistosomes (Schistosoma spp.), which give rise to a wide range of chronic but largely nonspecific symptoms. The most intense worm infections and related illnesses occur at school age (Partnership for Child Development 1998b, 1999) and account for some 12 percent of the total disease burden and 20 percent of the loss of disability-adjusted life years (DALYs) from communicable disease among schoolchildren (World Bank 1993).

Infected schoolchildren perform poorly in tests of cognitive function; when they are treated, immediate educational and cognitive benefits are apparent only for children with heavy worm burdens or with concurrent nutritional deficits. Treatment alone cannot reverse the cumulative effects of lifelong infection or compensate for years of missed learning, but studies suggest that children are more ready to learn after treatment for worm infections and may be able to catch up if this learning potential is exploited effectively in the classroom (Grigorenko and others, forthcoming). In Kenya, treatment reduced absenteeism by one-fourth, with the largest gains for the youngest children who suffered the most ill health (Miguel and Kremer 2004).

Malaria

Up to 5 percent of children infected with malaria early in life have residual neurological sequelae (Snow 1999). In areas of unstable transmission, malaria accounts for 10 to 20 percent of all-cause mortality among school-age children (Bundy and others 2000), and those who have suffered repeated attacks have poorer cognitive abilities. In Kenya, primary school students miss 11 percent of school days because of malaria, equivalent to 4 million to 10 million days per year (Brooker and others 2000).

Oral antimalarial treatment reduced school absenteeism by 50 percent in Ghana (Colbourne 1955); the use of insecticide-treated bednets in Tanzania reduced malaria and increased attendance (Shiff and others 1996). Girls in The Gambia were more than twice as likely to enroll in primary school if they had received malaria prophylaxis in early childhood (Jukes and others submitted).

HIV/AIDS

Although school-age children have the lowest infection prevalence of any age group (figure 58.2), an estimated 3.8 million children under 15 years of age have been infected with HIV and more than two-thirds have died (UNAIDS 2002). Even uninfected children suffer physically, socially, and psychologically through death or illness in their family (World Bank 2002). The proportion of orphans, most of whom are of school age, has risen from 2 to 15 percent in some African countries, with AIDS accounting for 50 percent of this increase. The number of orphans is expected to reach more than 25 million by 2010.

Figure 58.2

Age Prevalence of HIV/AIDS

School-age children with HIV infections have lower IQ levels and poorer academic achievement, language, and visual motor functioning. These deficits can be reduced or reversed with antiretroviral therapy. The improvement is greater for children of school age than for younger children.

Acute Respiratory Infection

Acute respiratory infection, the most common acute infection in school-age children globally, is a significant cause of absenteeism. Research in industrial countries (Cohen and Smith 1996) finds that flu infection affects attention and reaction time; colds primarily affect hand-eye coordination, as well as reduce the ability to tolerate high levels of noise and other distractions common to the classroom.

Malnutrition

Stunting (low height for age) is a physical indicator of chronic or long-term malnutrition, whereas underweight (low weight for age) is an indicator of both chronic and acute malnutrition. Both are common in school-age children (figure 58.3).

Figure 58.3

Mean Z-Scores of Height-for-Age of Boys in Five Countries

Girls who are better nourished are more attentive and more involved during class, and boys have improved classroom behavior and increased activity levels. One Z-score increase in height for age is associated with an increase of 0.1 standard deviation (SD) in tests of arithmetic and language. Stunted children enroll in school later than other children. School food-service programs have been successful in improving school attendance.

Short-Term Hunger

Hunger, which reduces ability to perform school tasks, is readily reversed by feeding. Children age 11 to 13 years in Jamaica improved their scores on arithmetic tests after one semester of receiving breakfast at school because they attended more regularly and studied more effectively (Simeon 1998). Missing breakfast impairs performance to a greater extent for children of poor nutritional status, who also benefit most from food intervention (Pollitt, Cueto, and Jacoby 1998; Simeon and Grantham McGregor 1989).

Micronutrient Deficiency

Micronutrient deficiencies may take several different forms, each with negative impacts on children's ability to perform well in school.

Obesity

An estimated 17.6 million children worldwide are overweight. Obesity is associated with underperformance in education. In low-income countries obesity is still rare, but the prevalence in the children of many middle-income countries is similar to that in the United States.

Developing a Programmatic Approach

The focus of school health and nutrition programs in low-income countries has shifted significantly over the past two decades away from a medical approach that favored elite schools in urban centers and toward an approach that improves health and nutrition for all children, particularly the poor and disadvantaged. This change began in the 1980s, when research showed not only that school health and nutrition programs were important contributors to health outcomes but also that they were essential elements of efforts to improve education access and completion, particularly for the poor.

In an effort to reconceptualize the relationship between health and education, the United Nations Education, Scientific, and Cultural Organization (UNESCO) hosted a series of workshops on this topic in the 1980s (Bundy 1989; Halloran, Bundy, and Pollitt 1989) and supported one of the first authoritative reviews of the area (Pollitt 1990). Similarly, the United Nations Development Programme, in conjunction with the Rockefeller, Edna McConnell Clark, and J. S. McDonnell Foundations supported the creation of the Partnership for Child Development to strengthen the evidence base across the education and health sectors and to support the dissemination of information (Berkley and Jamison 1990; Bundy and Guyatt 1996). This paradigm shift coincided with the World Conference on Education for All in Jomtien, Thailand, in 1990 and led to renewed efforts by countries and agencies to develop more effective programmatic approaches to school health and nutrition.

The United Nations Population Fund (UNFPA) has pioneered population and family life education (PopEd) as an intrinsic part of school curricula. In 1994, the International Conference on Population and Development placed specific emphasis on school health, including reproductive and sexual health. Efforts at country level have addressed PopEd both within the school system and outside, and the concept has evolved to include references to family life education, sex education, HIV/AIDS awareness and prevention, and life-skills programs. Today, approximately 84 countries have UNFPA-supported school health programs.

In 1995, the World Health Organization (WHO) launched its Global School Health Initiative to foster the development of health-promoting schools (HPSs) (WHO 1996). The concept started in Europe in the early 1990s, based on the Ottawa Charter of Health Promotion (WHO 1986), which recognized that health is created by caring for oneself and others, by being able to make decisions and have control over one's life and circumstances, and by creating conditions that support health for all. WHO's European Regional Office, the Council of Europe, and the Commission of the European Communities widely promoted the concept of HPSs to foster healthy lifestyles and develop environments conducive to health (European Commission, WHO Europe, and Council of Europe 1996). Although definitions vary among regions, countries, and schools, an HPS may be characterized as one that is constantly strengthening its capacity as a healthy setting for living, learning, and working. The initiative fosters the development of HPSs by the following:

• consolidating research and expert opinion to describe the nature and effectiveness of school health programs
• building capacity to advocate for the creation of HPSs and to apply the components to priority health issues
• strengthening collaboration and national capacities to assess the prevalence of important health-related behaviors and conditions and to plan and implement policies and programs that improve health through schools
• creating networks and alliances, including regional networks.

The key elements of how this approach is interpreted today are listed in table 58.1.

Table 58.1

Characteristics of Agency-specific School Health and Nutrition Programs, within the FRESH framework.

In the mid 1990s, the United Nations Children's Fund (UNICEF) began promoting the Child-Friendly Schools framework as a holistic way to promote children's rights as expressed in the Convention on the Rights of the Child (UNICEF 1990) and children's access to education as stated in the World Declaration of Education for All (UNESCO 1990). This approach included a gender-sensitive component, which was further strengthened when girls' education became the first priority in UNICEF's Medium Term Strategic Plan, 2002–5. Another key element is skills-based health education, including life skills, which has been promoted through UNICEF with partner organizations as part of HPSs, child-friendly schools, and the framework for Focusing Resources on Effective School Health (FRESH). Research shows that this approach is more effective than traditional strategies, which tend to be didactic and to focus on scientific information alone. In contrast, skills-based health education uses the experiences of students as the starting point and explores the links between knowledge, attitudes, and the interpersonal skills required to promote health and learning (UNICEF, WHO, World Bank, UNFPA, UNESCO 2003). The approach is interactive, activity based, and flexible so that it can be used to address a range of health and social issues, including HIV/AIDS, sanitation, drug use, violence and bullying, nutrition, and cross-cutting issues such as gender and culture. Some key elements of how the child-friendly schools approach is interpreted currently, including its focus on healthy and protective learning environments, are listed in table 58.1.

Also during the 1990s, the World Bank Human Development Network sought to support countries in implementing school health and nutrition programs (Del Rosso and Marek 1996; World Bank 1993) and launched an International School Health Initiative with the aim of raising awareness among decision makers in the education sector.

Thus, the 1990s were characterized by the creation of a number of apparently separate programs to promote and support school health. However, analysis at the country level revealed that although the various agency initiatives used different "prisms" to view school health—public health for WHO, quality education for UNESCO, and child rights for UNICEF—the core activities for all the programmatic approaches were essentially the same.

FRESH Framework

A major step forward in international coordination and cohesion was achieved when the FRESH framework was launched at the World Education Forum in Dakar in April 2000 (World Bank FRESH Toolkit 2000). Among the early partners in this effort were the Education Development Centre, Education International, the Partnership for Child Development, UNESCO, UNICEF, the World Food Programme (WFP), WHO, and the World Bank. This partnership recognizes that the goal of universal education cannot be achieved while the health needs of children and adolescents remain unmet and that a core group of cost-effective activities can and must be implemented across the board to meet those needs and to deliver on the promise of EFA.

The expanded commentary on the Dakar Framework for Action reflects the recommendations of this partnership and describes three ways in which health relates to EFA: as an input and condition necessary for learning, as an outcome of effective quality education, and as a sector that must collaborate with education to achieve the goal of EFA. In the follow-up to the Dakar Forum, UNESCO designated FRESH as an interagency flagship program that will receive international support as a strategy to achieve EFA.

The FRESH framework, which is based on good practice recognized by all the partners, provides a consensus approach for the effective implementation of health and nutrition services within school health programs. The framework proposes four core components that should be considered in designing an effective school health and nutrition program and suggests that the program will be most equitable and cost-effective if all of these components are made available, together, in all schools:

• Policy: health- and nutrition-related school policies that are nondiscriminatory, protective, inclusive, and gender sensitive and that promote the nutrition and physical and psychosocial health of staff, teachers, and children
• School environment: access to safe water and provision of separate sanitation facilities for girls, boys, and teachers
• Education: skills-based education, including life skills, that addresses health, nutrition, HIV/AIDS prevention, and hygiene issues and that promotes positive behaviors
• Services: simple, safe, and familiar health and nutrition services that can be delivered cost-effectively in schools (such as deworming services, micronutrient supplements, and nutritious snacks that counter hunger) and increased access to youth-friendly clinics.

The FRESH framework further proposes that these four core components can be implemented effectively only if they are supported by strategic partnerships between the following groups:

• health and education sectors, especially teachers and health workers
• schools and the community
• children and others responsible for implementation.

Adopting this framework does not imply that these core components and strategies are the only important elements; rather, implementing all of these in all schools would provide a sound initial basis for any pro-poor school health program.

The common focus has encouraged concerted action by the participating agencies. It has also provided a common platform on which countries, agencies, donors, and civil society can support all programs, including agency-specific programs (table 58.1). Another important consequence of the FRESH consensus framework has been to offer a common point of entry for new efforts to improve health in schools, as illustrated by the three examples in box 58.1.

Box 58.1

Three Efforts to Improve Health in Schools. The Multiagency Effort to Accelerate the Education Sector Response to HIV/AIDS in Africa This effort, coordinated by a Working Group of the UNAIDS Inter-Agency Task Team on HIV/AIDS and Education, promotes (more...)

This consensus approach has increased significantly the number of countries implementing school health reforms. The simplicity of the approach, combined with the enhanced resources available from donor coordination, has helped ensure that these programs can go to scale. Annual external support from the World Bank for these actions approaches US$90 million, targeting some 100 million schoolchildren.

Common Interventions

Table 58.2 lists some specific interventions commonly combined within the school health intervention package, but it should be recognized that not all of these interventions will be needed or be appropriate for all locations. Some interventions are synergistic: for example, worm infection will be addressed by the provision of latrines, the promotion of hand washing, relevant health and hygiene education, and deworming services. Similarly, HIV/AIDS infection among youths will be addressed by ensuring girls' participation in school, offering skills-based health education (including life skills), offering peer education, providing access to health clubs, and providing access to treatment for sexually transmitted infections (STIs) at clinics. It is also apparent that whereas some interventions promote multiple outcomes—for example, skills-based health education and life-skills development can help promote positive behaviors that prevent STIs and substance abuse—other interventions may have a single focus, such as iron supplementation to avoid anemia.

Table 58.2

Common Interventions within a School Health Program.

Out-of-School Children

More than 100 million school-age children are out of school; 60 percent are girls (UNESCO 1993). School health programs in Guinea and Madagascar have demonstrated that many of these children will take advantage of simple services, such as deworming, provided in schools (Del Rosso and Marek 1996); the school acts essentially as a community center. It also has been demonstrated that deworming programs in schools benefit out-of-school children by reducing disease transmission in the community as a whole (Bundy and others 1990).

Nevertheless, it is apparent that out-of-school children cannot benefit from many of the important components of school-based programs, such as skills-based health education and life-skills development programs to prevent HIV/AIDS. Reaching these children requires more flexible approaches that combine the best of nonformal, informal, and community-based approaches (see chapter 59).

Economic Benefits of Long-Term Improvements in IQ

School health interventions can yield considerable economic benefits through returns to wages and productivity if they translate into improved cognitive functioning and IQ in adulthood.

For the United States, Zax and Rees (2002) estimate conservatively that an increase in IQ of 1 SD is associated with an increase in wages of more than 11 percent, falling to 6 percent when controlling for other covariates. Similar estimates for the relationship between IQ and earnings have been made for Indonesia (Behrman and Deolalikar 1995) and Pakistan (Alderman and others 1997) and in a review of developing countries (Glewwe 2002). In South Africa, an increase of 1 SD in literacy and numeracy scores was associated with a 35 percent increase in wages (Moll 1998). Extrapolating these results, a 0.25 SD increase in IQ, which is a conservative estimate of the benefit resulting from a school health intervention, would lead to an increase in wages of from 5 to 10 percent.

Economic Benefit of Improved School Attendance

School health interventions can raise adult productivity not only through higher levels of cognitive ability, but also through their effect on school participation and years of schooling attained. Healthier children are more likely to attend, and modest improvements in examination scores can be associated with continuation in schooling.

Malaria chemoprophylaxis given in early childhood in The Gambia led to an increase of more than one year in primary schooling. In preschool children in Delhi, iron supplementation was associated with an increase of 5.8 percent in rates of participation at the preschool level (Bobonis, Miguel, and Sharma 2004). In western Kenya, deworming treatment improved primary school participation by 9.3 percent, with an estimated 0.14 additional years of education per pupil treated (Miguel and Kremer 2004). On the basis of crude estimates of returns to schooling, an increase of 9.3 percent in participation rates results in a return of US$44. Miguel and Kremer (2004) conclude that these benefits still outweigh the costs even if increased school participation leads to greater costs in teacher compensation through the need for additional teachers. They note that the benefit-cost ratio remains over 10 even if the rate of return to an additional year of schooling is as low as 1.5 percent. These results suggest that for realistic estimates of returns to schooling, the net present discounted value of lifetime earnings is likely to be high compared to the costs of treatment even for small gains in school participation. ¹

In the absence of studies estimating the direct link between school health interventions and school participation, the relationship can be estimated indirectly by considering the effect of interventions on test scores and the implications that improved test scores have for school participation. Improvements in cognitive function can be converted into an equivalent number of years of schooling. For example, Jukes and others (2002) found that heavy schistosomiasis was (nonsignificantly) associated with a decrease in arithmetic scores of 1.35 marks (0.25 SD). An extra year of schooling was associated with an increase in arithmetic scores of 2.24 marks (0.42 SD). Thus, the negative effect of heavy schistosomiasis was equivalent to missing just over half a year of schooling. The cognitive gains from an extra year of schooling can also be estimated retrospectively: in a study of adults in South Africa, each additional year of primary schooling was associated with a 0.1 SD increase in cognitive test scores (Moll 1998). According to these estimates, a typical increase of 0.25 SD associated with school health and nutrition programs is equivalent to an additional 2.5 years of schooling.

Liddell and Rae (2001) assessed the direct effect of test scores on grade progression in Africa. Each additional SD scored in first-grade exams resulted in children being 4.8 times as likely to reach seventh grade without repeating a year of schooling. ² According to these estimates, an increase of 0.25 SD in examination scores, which is typically achieved by school health and nutrition programs, will make children 1.48 times ³ as likely to complete seventh grade, which implies that the extra cumulative years of schooling attributable to the school health intervention average 1.19 years per pupil. The previous estimates for added years of schooling owing to school health interventions range from seven months to two years. Increased years of schooling are associated with, among other outcomes, higher worker productivity and generally higher productivity in nonmarket production activities, including greater farmer efficiency and productivity (Jamison and Lau 1982; Psacharopoulos and Woodhall 1985; Strauss and Thomas 1995). Psacharopoulos and Patrinos (2002) summarize a wide range of studies that focus on individual wage earnings. For Sub-Saharan Africa, they find a 12 percent rate of return to one additional year in school, compared with 10 percent for Asian countries. These returns are very high, even allowing for a portion of the return to years of schooling to be capturing ability and factors other than schooling itself (Card 2001).

Education brings benefits beyond improved earnings. One year of extra education for girls can lead to a reduction of from 5 to 10 percent in infant mortality (Schultz 1993). Five extra years of education for women in Africa could reduce infant mortality by up to 40 percent (Summers 1994).

Economic Benefits of Programs

The educational gains from school health and nutrition programs should be considered in the context of alternative educational inputs, such as improving teacher salaries and qualifications, reducing class size, improving school facility infrastructure, and providing instructional materials. Many studies relate student outcomes to school characteristics, but few of these studies provide information on the relative or actual costs of the educational inputs. The costs, however, are substantially greater than for the school health interventions considered here. Despite the higher costs, the evidence from the few randomized evaluations that have been conducted suggests that the scale of effect of additional education inputs is typically low (see discussion in Miguel and Kremer 2004). A review of studies showed that instructional materials (such as additional textbooks) had the highest productivity, raising student test scores significantly more than other inputs for each dollar spent. However, even these interventions have only a weak effect. In a randomized experiment in Kenya, for example, providing textbooks had no effect on the bottom three quintiles of students and raised test scores by only 0.2 SD for the upper two quintiles. Relating these results to the findings in the previous section and to the annual per pupil costs, school health interventions appear very cost-effective compared to the highest-productivity, more traditional education inputs.

Recently, conditional cash-transfer programs have been viewed as potentially very cost-effective methods to increase school enrollment. These programs are generally large in scope, representing a commitment of between 0.1 and 0.2 percent of gross national income. The Progresa program in Mexico is estimated to have increased enrollment by 3.4 percent and to have increased schooling by 0.66 years, with an average cash transfer (for grades 3 to 8) of about US$136 per child per school year (assumed to be 180 days). Gains from a similar program in Nicaragua were estimated at 0.45 years of school at a cost of US$77 per year. If we compare these results with those presented for school health and nutrition programs, the conditional cash-transfer approach is, in both cases, apparently at the lower end of effectiveness and the higher end of cost.

Policy and Economic Issues in Defining Sectoral Roles in Intervention

A negative correlation between income level and both ill health and malnutrition is clearly demonstrated both in cross-country comparisons and within countries (see de Silva and others 2003), partly because poverty promotes both disease and an inadequate diet. Similarly, children who are not enrolled in school come from households with lower income levels (Filmer and Pritchett 2001). This fact suggests that school health services that are pro-poor and specifically linked to efforts to achieve universal participation in education will have a greater return.

Early school health programs, particularly in colonial Africa, were intended to serve the minority of children who had access to school in urban centers or elite boarding facilities. They relied on specific infrastructures and services—such as mobile health teams, school visits, school nurses, and in-school clinics—that were additional to the normal range of health service provision. This approach has proven difficult to make universally available, even in middle-income countries. A school nurse program in KwaZulu-Natal, for example, achieved inadequate coverage (18 percent of the target population) and little referral or follow-up treatment of cases of ill health detected, despite a relatively high investment of US$11.50 per student targeted per year (World Bank FRESH Toolkit 2000). As shown in the following examples, using the FRESH framework approach reduces costs significantly and enhances both coverage and outcomes.

An important element of the new approach to school health is a focus on minimizing the need for clinical diagnosis. Mass delivery of services, such as deworming and micronutrient supplementation, is preferable on efficacy, economic, and equity grounds to approaches that require diagnostic screening (Warren and others 1993).

Sectoral Roles in Implementation

Table 58.4 gives examples from low- and middle-income countries of how the four core components of FRESH are being supported by different approaches. In about 85 percent of programs reviewed, school health and nutrition programs are delivered and funded by the public education sector, with a formal role for the health sector in design and supervision.

Table 58.4

Nine Low- and Middle-Income Countries and How They Use FRESH.

Although this public sector "mainstream" model has proven the most popular approach, it is not the only successful one. In some cases, the public sector has identified appropriate options and developed operational manuals but then has used a social fund to provide direct support to communities and has used schools to select and implement the most relevant actions locally, often with the assistance of nongovernmental organizations (NGOs). In other cases, services have been contracted out by the public sector, and in some middle-income countries, the move toward a demand-led approach has resulted in a private sector service.

The private sector approach has proven sustainable over nearly two decades in urban Indonesia but may require a technical infrastructure and local market base that are inappropriate for predominantly rural low-income countries. The approach is modeled on a program initiated in Japan in 1948, which relied on private sector technicians, working independently at first but later formalized within the Japan Association of Parasite Control, who conducted stool examinations and then treated infected individuals for a per capita fee equivalent to approximately US$0.74 in 2004. At its peak, the private sector program conducted some 12 million examinations annually, implying a turnover of nearly US$9 million at today's prices. The prevalence of roundworm infection fell from a high of 73 percent in 1949 to less than 0.01 percent by 1985.

Although a private sector response is effective in some circumstances, overall the characteristics of school health and nutrition programs make a compelling case for public sector intervention. First, treatment externalities may create external benefits to others in addition to the benefit for the treated individual. This situation is clearly the case for communicable disease interventions, especially against worm infection. Second, some forms of intervention (such as vector control, health education campaigns, epidemiological surveillance, and interventions that have strong externalities) are almost pure public goods; that is, no one can be excluded from using the goods or service they deliver, and thus the private sector is unlikely to compete to deliver these goods. Finally, there is typically little private demand for general preventive measures, such as information on the value of washing hands. None of these factors is an argument against a private sector role in service delivery, but they do suggest that private sector demand is likely to be greater in middle-income populations and where public sector actions have created a demand.

Roles of Key Stakeholders in Implementation

There are many ways to approach the delivery of school health, but these diverse experiences suggest common features—in particular, the consistency in the roles played by government and nongovernmental agencies as well as other partners and stakeholders (table 58.5). In nearly every case, the Ministry of Education is the lead implementing agency, reflecting both the goal of school health programs in improving educational achievement and the fact that the education system provides the most complete existing infrastructure for reaching school-age children. However, the education sector must share this responsibility with the Ministry of Health, particularly because the latter has the ultimate responsibility for health of children. It is also apparent that the program's success depends on the effective participation of numerous other stakeholders, including civil society, and especially the beneficiaries and their parents or guardians. The children and their families are the clients of these programs, and their support for program implementation is critical to the program's success.

Table 58.5

Roles of Agencies, Partners, and Stakeholders in School Health and Nutrition Programs.

Key Issues in Designing Effective Programs

The diverse experiences of school health programming suggest some key elements that are common contributors to success in many programs.

• Focus on education outcomes. Making explicit links among school health programs and learning and education sector priorities (especially EFA and gender equity) helps ensure the commitment of the sector to program support and implementation.
• Develop a formal, multisectoral policy. Education sector actions in health require the explicit agreement of the health sector. This potential tension can be resolved by defining sectoral responsibilities at the outset; failure to enter into dialogue has led, in Africa and Central Asia, to some health sectors resisting teacher delivery of deworming drugs, despite WHO recommendations.
• Initiate a process of wide dissemination and consultation. Because there are multiple stakeholders, implementers, enablers, and gatekeepers, a process of consultation is necessary to establish ownership and to identify obstacles before they constrain progress. The process should involve at least community-based organizations, NGOs, faith-based organizations, pupils, and teacher associations. In one country in East Africa, lack of prior agreement on the content of sexuality education delayed implementation for more than three years.
• Use the existing infrastructure as much as possible. Building on existing curriculum opportunities and the network of formal and nonformal teachers will accelerate implementation and reduce costs. Programs that rely on the development of new delivery systems—mobile school health teams, a cadre of school nurses—take longer to establish and are expensive and complicated to sustain and take to scale.
• Use simple, safe, and familiar health and nutrition interventions. Success in rapidly reaching all schools depends on stakeholder acceptance, which is more likely if the interventions are already sanctioned by local and international agencies and are already in common use by the community.
• Provide primary support from public resources. Compelling arguments exist for public investment in school health programs: the contribution to economic growth, the high rate of return, the large externalities, and the fact that the majority of interventions are public goods.
• Be inclusive and innovative in identifying implementation partners. Although public resources are crucial for school health programs, contributions from outside the public sector can be vital. NGOs have proven effective in supporting public sector programs through training and supervision, particularly at local levels. Although market failure appears to have largely precluded the private sector from effectively implementing national programs in low-income countries, examples of successful contributions do occur, particularly in dense urban populations and in middle-income countries.

Cost-Effectiveness of School-based HIV/AIDS Prevention

Substantial evidence suggests that skills-based health education, including life-skills development programs, can promote positive behaviors and reduce the risks of exposure to HIV infection, and that girls' education programs have similar effects (Kirby 2002). Evidence also exists for a positive effect of completing education on HIV prevalence (de Walque 2004; World Bank 2002). What is lacking is direct evidence about the contribution that school-based prevention programs can make in reducing the incidence of HIV infection, as well as evidence for the relative cost-effectiveness of such programs compared with existing efforts to promote education completion and girls' education.

Cost-Effectiveness of Malaria Programs

Malaria occurs commonly in schoolchildren, particularly in areas of unstable transmission in Africa and Asia. It is a leading source of mortality in this age group and adversely affects education by reducing school attendance, cognition, learning, and school performance. Current school-based approaches focus on knowledge of the disease and the use of impregnated bed-nets but do not address the need for treatment of affected children. Yet presumptive treatment by teachers has been shown to significantly reduce mortality (Pasha and others 2003), and intermittent preventive treatment also shows considerable promise (Brooker and others 2000). There is a need to confirm the success of school-based treatment in different epidemiological settings and to address questions about the cost and sustainability of this approach.

Cost-Effectiveness of Targeting Food Aid

The high prevalence of malnutrition in children continues to be a major challenge for low-income countries. Providing food to children at school is often seen as an important part of the solution and is a major focus for food aid. However, the nutrition literature suggests that ensuring good nutrition earlier in life—certainly before 3 years of age, but perhaps earlier—is essential to ensuring an appropriate development trajectory throughout life (see chapter 27). Where food is limiting, it raises the question whether the first target should be preschool rather than school-age children. This debate has been blurred by admixing the nutrition outcomes with broader social and education issues. Clearly, providing a meal at school is socially desirable and can offer education benefits for children who otherwise would have to walk often long distances home to eat or remain hungry. It is also clear that schools represent an extensive and established network for providing nutrition interventions to very large numbers of children at a low cost per child. No comparable network exists to reach preschool children. However, from a nutritional perspective, it remains unclear whether ensuring good nutrition early in life has more effect on subsequent development—including educational achievement—than providing food at school age.