This chapter presents the investment case for providing an integrated package of essential health services for children attending primary schools in low- and middle-income countries (LMICs). In doing so, it builds on chapter 20 in this volume (Bundy, Schultz, and others 2017), which presents a range of relevant health services for the school-age population and the economic rationale for administering them through educational systems. This chapter identifies a package of essential health services that low- and middle-income countries (LMICs) can aspire to implement through the primary and secondary school platforms. In addition, the chapter considers the design of such programs, including targeting strategies. Upper-middle-income countries and high-income countries (HICs) typically aim to implement such interventions on a larger scale and to include and promote additional health services relevant to their populations. Studies have documented the contribution of school health interventions to a range of child health and educational outcomes, particularly in the United States (Durlak and others 2011; Murray and others 2007; Shackleton and others 2016). Health services selected for the essential package are those that have demonstrated benefits and relevance for children in LMICs. The estimated costs of implementation are drawn from the academic literature. The concept of a package of essential school health interventions and its justification through a cost-benefit perspective was pioneered by Jamison and Leslie (1990).
As chapter 20 notes, health services for school-age children can promote educational outcomes, including access, attendance, and academic achievement, by mitigating earlier nutrition and health deprivations and by addressing current infections and nutritional deficiencies (Bundy, Schultz, and others 2017). This age group is particularly at risk for parasitic helminth infections (Jukes, Drake, and Bundy 2008), and malaria has become prevalent in school-age populations as control for younger children delays the acquisition of immunity from early childhood to school age (Brooker and others 2017). Furthermore, school health services are commonly viewed as a means for building and reinforcing healthy habits to lower the risk of noncommunicable disease later in life (Bundy 2011).
This chapter focuses on packages and programs to reach school-age children, while the previous chapter, chapter 24 (Horton and Black 2017), focuses on early childhood interventions, and the next chapter, chapter 26 (Horton and others 2017), focuses on adolescent interventions. These packages are all part of the same continuum of care from age 5 years to early adulthood, as discussed in chapter 1 (Bundy, de Silva, and others 2017). A particular emphasis of the economic rationale for targeting school-age children is to promote their health and education while they are in the process of learning; many of the interventions that are part of the package have been shown to yield substantial benefits in educational outcomes (Bundy 2011; Jukes, Drake, and Bundy 2008). They might be viewed as health interventions that leverage the investment in education.
Schools are an effective platform through which to deliver the essential package of health and nutrition services (Bundy, Schultz, and others 2017). Primary enrollment and attendance rates increased substantially during the Millennium Development Goals era, making schools a delivery platform with the potential to reach large numbers of children equitably. Furthermore, unlike health centers, almost every community has a primary school, and teachers can be trained to deliver simple health interventions, resulting in the potential for high returns for relatively low costs by using the existing infrastructure.
This chapter identifies a core set of interventions for children ages 5–14 years that can be delivered effectively through schools. It then simulates the returns to health and education and benchmarks them against the costs of the intervention, drawing on published estimates. The investment returns illustrate the scale of returns provided by school-based health interventions, highlighting the value of integrated health services and the parameters driving costs, benefits, and value for money (the ratio of benefits to costs). Countries seeking to introduce such a package need to undertake context-specific analyses of critical needs to ensure that the package responds to the specific local needs.
© 2017 International Bank for Reconstruction and Development / The World Bank.