Policy Brief | School Health Programme

POLICY BRIEF SCHOOL CHILDREN HEALTH: NEED FOR INSTITUTIONALISATION OF SCHOOL HEALTH PROGRAMME IN PUNJAB

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WHY SCHOOL HEALTH IS IMPORTANT? Poor quality human resource is the fundamental barrier to economic development in Pakistan (and other developing countries). The indicator for this is Pakistan’s low ranking at 146 among 187 countries on the United Nations Human Development Programme (UNDP)’s Human Development Index (HDI). The HDI is a summary measure for assessing long-term progress in three basic dimensions of human development: a long and healthy life, access to knowledge and a decent standard of living. Education and health are the most essential and inter-dependent determinants of human development. It is well established that good health is crucial for effective learning and education in turn is essential for good health. Health and education are also basic human rights.

Education Quality Human Resources Health

National Development and Global Competitiveness

There is clear evidence at the global level that the health of school children is important for:   

Achieving education targets and goals including increasing enrolment, reducing dropout rate and enhancing quality of education and learning outcome; Health promotion in the community: Health and nutrition literate school children and teachers can become a very important resource for health promotion and life style change in the community more especially in developing countries where there are more community–based education sector resources than health resources.

Achieving economic development goals by enhancing the quality of human resources produced by the country.

International development agencies are therefore urging national governments to implement holistic school health programmes to ensure the achievement of educational and national development goals. A holistic programme is expected to cover: 1. School Health Environment: Healthy school environment is an essential prerequisite for learning. Schools need to have potable water supply, gender and culturally sensitive sanitary latrines, well ventilated and well lighted classrooms of adequate size, playgrounds and disabled and child friendly infrastructure.

2. School Health Education: Schools need to integrate health and hygiene education in the school curricula and teachers training.

3. School Health Services: School health services must include regular screening of students and referral arrangements between schools and health services, regular de-worming campaigns and availability of a school dispensary.

4. School Nutrition Programme: Nutrition programmes need to include micronutrient supplementation, school meals and nutrition education.

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SCHOOL HEALTH IN PUNJAB-FINDINGS OF THE ILM IDEASFUNDED NCRP SCHOOL HEALTH SURVEY Pakistan and more specifically the Punjab province recognise the importance of school health and have been experimenting with different approaches since the 1970s. The major initiatives undertaken in the new millennium include the Tawana Pakistan (school meals) programme, the National Commission for Human Development (NCHD)’s SHP 2005-2011 and the currently on-going Punjab Health Sector Reforms Programme’s SHP launched in 2005. The Ilm Ideas funded School Health Survey 2014 was undertaken by the Nur Center for Research and Policy (NCRP), an associate organisation of Fatima Memorial System (FMS), Shadman, Lahore with the objective of documenting the current status of public secondary school children’s health and nutritional status; assessing the impact of past and ongoing SHPs on students health and nutrition literacy and practices; and recording the perspectives of stakeholders on the health and nutrition status and needs of school children and their views on barriers to SHP implementation. The findings are summarised below: 1. PUBLIC SECTOR SECONDARY SCHOOL CHILDREN HAVE POOR HEALTH AND NUTRITIONAL STATUS : a. Sickness was responsible for up to 50 percent of school absenteeism. b. Fever, headaches, earaches, toothaches and stomach problems were common reasons for absenteeism. c. Twenty percent girls and 22 percent boys had intestinal worm infection and 22 percent girls and 21 percent boys had received de-worming medicine. d. Low weight for age was found in 7 percent girls and 17 percent boys; and 11 percent of boys age 14 years and more were stunted.

2. PARENTS OF MOST OF THESE CHILDREN CANNOT AFFORD THEIR ADEQUATE CARE AND NUTRITION : Majority of these children come from low income poor homes and their parents have limited resources to provide them with adequate nutrition and health care in a period of their life cycle in which rapid growth occurs; 3. SCHOOL ENVIRONMENT NOT ‘HEALTH PROMOTING ’ IN MOST SCHOOLS : Many significant gaps in the school environments were found which are not only likely to affect the physical health of the children but also their school performance and educational achievement. a. b. c. d. e.

No playgrounds in 7.5% girls’ and 10% boys’ schools Inadequate drinking water arrangements in 31.2% girls’ and 41.0% boys’ schools Sanitary latrines absent from 27.4% girls’ and 22% boys’ schools No libraries in 50.0% girls’ and 41.0% boys’ schools Absent dispensaries and first aid arrangements in all schools surveyed

4. LIMITED IMPACT OF PAST AND CURRENTLY ON -GOING SHPS:

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While some impact of past and currently on-going SHPs was found on the children health and nutrition knowledge, there was no impact on the personal hygiene practices and nutrition status. This piece of evidence indicates that the students owing to poverty are unable to put into practice what they learn about good nutrition and personal hygiene.

Reasons for the limited impact identified by health and education managers included: a. School health packages implemented and being implemented wee/are incomplete; b. As pointed out by health and education managers there has been poor coordination between health and education sectors in SHPs implemented to date; c. SHPs implemented to date have been dependent on donor funding which limited their scope as well as sustainability.

5. GAPS AND BARRIERS TO IMPLEMENTATION AND INSTITUTIONALISATION : a.

b.

c. d. e.

Limited role of health professionals was found on the health and nutrition knowledge of school children. Teachers (46%) and parents (45%) were found to be the main sources of the students’ knowledge with only 5-6 percent identifying health services and health professionals as their source of advice.

No ownership of currently-ongoing SHP among school management and teachers: Schools were reluctant to take on responsibility for the implementation of health programmes owing to: i. Overburdened teachers ii. Inadequate funding and other resources.

Parents and families role is not recognised in SHPs: There is little involvement of Parents and community members in SHPs and other school health promoting activities. Their role in the effective implementation of such programmes and activities is not recognised; Questionable sustainability: Managers were sceptical about the impact of SHP and its sustainability owing to their donor dependence, uncoordinated implementation and lack of transparency.

Document review showed a lack of political commitment to the health of school children as indicated by the absence of specific legislation and policies on school health. This may also be responsible for programmes’ dependence on donor funding.

6. SCHOOL CHILDREN AS HEALTH PROMOTERS IN THE COMMUNITY: Fifty percent girls and 37% boys informed that they convey health and nutrition knowledge to their parents and families and over 90% were convinced that their families listened to them. Their relevant and effective health education in schools can help with health promotion in the community;

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RECOMMENDATIONS FOR INSTITUTIONALISATION AND EFFECTIVE IMPLEMENTATION OF SCHOOL HEALTH PROGRAMME IN PUNJAB 1. Institutionalise School Health Programmes(SHP) in the Education System with due recognition of the role of health, agriculture, food, social welfare, public health engineering, Zakat and USHER (funding for poor children meals and supplements) and others.

2. Implement the whole SHP package including school health services, de-worming, school meals and micronutrient supplementation.

S PECIFIC R ECOMMENDATIONS FOR EDUCATION D EPARTMENT 1. L EGISLATION Education is a fundamental right of all children aged 5-16, guaranteed through Article 25A of the Constitution of the Islamic Republic of Pakistan. Institutionalisaton of SHP will help ensure access to education for all through boosting school enrollment, reducing dropouts and enhancing quality of education and education outcomes. The Punjab government needs to enact laws to ensure institutionalization and effective implementation of School Health Programmes. Following are school meals related laws of some countries: i. ii.

The Healthy Hunger-Free Kids Act (HHFKA), United States includes a strong package of provisions designed to increase funding for healthy school meals.

Rajasthan Right of Children to Free and Compulsory Education Rules, 2011, states that the School Management Committee shall (i) monitor the implementation of the mid-day meal in the school. Mid-day meal programme was given legal cover through the directive of the Indian Supreme Court in response to a Right to Food Litigation. The Supreme Court directed the government to fully implement its’ scheme of providing cooked meals to all children in primary schools. This landmark direction converted the mid-day meal scheme into a legal entitlement, the violation of which can be taken up in the court of law.

2. P OLICY A comprehensive, overarching School Health and Nutrition Policy needs to be developed recognizing the specific needs of school going children and adolescent. The policy should be primarily anchored to education policy with the roles of health and other departments like food and agriculture, social welfare and sports etc. clearly defined in its implementation. Water, Sanitation and Hygiene (WASH) related projects must also cover schools.

3. C OORDINATION AND MONITORING Functioning coordination mechanisms between Health and Education and other relevant departments must be established to ensure the effective implementation of school health and nutrition programmes. Monitoring and periodic

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third party evaluations must be integral part of programmes. Parents and community including school councils may be authorised to undertake monitoring. In 2002 a school health steering committee was constituted by the Punjab government to oversee and coordinate school health programme. This initiative needs to be revisited.

4. F UNDING Funding is always a major challenge for implementation of policies and programmes. Funding for SHPs must become a regular part of education budgets as is done by other countries. Funding comes from diverse sources but federal and provincial funds are the main sources. Departments which are identified under policy and strategy as partners in SHP contribute funds and other resources to the programme. Resources can be mobilized from the corporate sector under social responsibility and philanthropy. Social Welfare and Zakat funds can also be tapped for the purpose. The most expensive component of SHP is school meals. Sustainable models for provision of school meals need to be developed.

5. H UMAN RESOURCES FOR SHP S Adequate and competent human resources are needed for the implementation of SHP in thousands of schools. School Health and Nutrition Supervisors are overburdened and need to be supported. Education department resources, which are quantitatively more than the health department, need to be mobilised for the effective implementation of the programme. However the needs of the education department in this regard need to be assessed and met. Teachers if their number is increased and are given training can take on some of the responsibilities of SHNSs. Community volunteers and school council members can be trained to assist SHNS and teacher in screening, referrals and health education. Teachers need to be trained on providing first aid to students in case of emergencies.

6. R OLE OF P ARENTS AND COMMUNITY Lack of awareness amongst parents is a major factor responsible for children’s poor health and nutrition. Parents’ lack of awareness of low cost alternatives for high nutrition value foods contributes to children malnutrition. Schools have the infrastructure to organize health and nutrition awareness creation activities if supported with necessary resources and cooperation and collaboration of other departments such as health, food and agriculture etc.

Parents and community members can also be mobilised to assist school management and SHNSs in overseeing school cafeteria food and the food supplied by vendors in the schools vicinity.

Parents and community members can also be mobilized to bridge the communication gap between education and health and other relevant services at the community level.

7. R OLE OF SCHOOLS AND STUDENTS IN H EALTH P ROMOTION Schools, teachers and students are there at the grass root level to assist and facilitate the public health services in promoting healthy life styles and preventing diseases. As is being recognised now, there are many more schools than health facilities, many more teachers than public health professionals and millions of students to disseminate health and nutrition messages to families and community. Recognition of this at policy level and mandatory collaboration and coordination between health and education sectors and other relevant stakeholders can prove to be the most cost effective approach for health promotion to-date.

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