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First meeting / Document 15

Focusing Resources on Effective School Health (FRESH)
J. Jones, WHO and A.M. Hoffmann-Barthès, UNESCO

The FRESH goal is to improve learning and educational achievement by improving the health and nutritional status of school-age children. The FRESH partnership was developed by the World Bank, WHO,UNICEF and UNESCO and launched at the World Education Forum in Dakar in April 2000.

"We are committed to the centrality of education in the development process. But we cannot look at education in isolation. It needs to be looked at within the framework of a comprehensive approach. You need to have equity and justice. You need to have governance. You need to have health care, and we have programs-the FRESH Start program, for example-where the linkage between health and education is so clear."
James D. Wolfensohn President, The World Bank
"WHO's domain is health. But it is clear that without proper education, health suffers. And without proper health, good education is not possible. In this our work is linked and it depends on each other.…An effective school health programme, consisting of four core components - health-related policies, water and sanitation, skills-based health education and school health services - can be one of the most cost-effective investments a nation can make to simultaneously improve education and health."
Gro Harlem Brundtland Director-General, World Health Organization
"Schools must have adequate hygiene and sanitation facilities, needed health and nutrition services, and school policies which guarantee physical and mental health, safety, and security…And above all, children must end up learning what they are meant to, and need, to learn."
Carol Bellamy Executive Director, UNICEF
"If the bodies of the learners are healthy, then their minds will be more receptive to learning. By ensuring the health and education of your people, you are offering them the strongest tool of all for the eradication of poverty. The FRESH initiative is in this respect not only a major flagship programme in working towards education and health for all but also in fostering the role of education in building a more caring and equitable world."
Koïchiro Matsuura Director-General, UNESCO

The FRESH framework is the starting point for developing an effective school health hygiene and nutrition program. It provides a framework from which individual countries will develop their own strategy to match local needs, with the support by intersectoral partnerships within the fore core components of FRESH:

(i) Health-related school policies in schools
(ii) Provision of safe water and sanitation to provide a healthy learning environment
(iii) Skills-based approach to health, hygiene, and nutrition education
(iv) School-based health and nutrition services

Focusing Resources on Effective School Health: A FRESH Start to enhancing the Quality and Equity of Education

"Education for All" means ensuring that all children have access to basic education of good quality. This implies creating an environment in schools and in basic education programmes in which children are both able and enabled to learn. Such an environment must be effective with children, friendly and welcoming to children, healthy for children, inclusive and protective of children and gender sensitive. The development of such child-friendly learning environments is an essential part of the overall efforts by countries around the world to increase access to, and improve the quality of, their schools.

Poor health and malnutrition are important underlying factors for low school enrollment, absenteeism, poor classroom performance, and early school dropout, as reflected in the World Declaration on Education for All. Programmes to achieve good health, hygiene and nutrition at school age are therefore essential to the promotion of basic education for all children.

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 in order to fully participate in education and gain its maximum benefits. Early childhood care programmes and primary schools which improve children's health and nutrition can enhance the learning and educational outcomes of 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.

Background

Ensuring that children are healthy and able to learn is an essential component of an effective education system. This is especially relevant to efforts to achieve education for all in the most deprived areas. Increased enrolment and reduced absenteeism and drop-out 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, who have the most to gain educationally from improved health. Effective school health programmes that are developed as part of community partnerships provide one of the most cost-effective ways to reach adolescents and the broader community and are a sustainable means of promoting healthy practices.

Improving the health and learning of school children through school-based health and nutrition programmes is not a new concept. Many countries have school health programmes, and many agencies and non-government organizations (NGO's) have decades of experience. These common experiences suggest an opportunity for concerted action by a partnership of agencies and NGO's to broaden the scope of school health programmes and make them more effective. Effective school health programmes will contribute to the development of child-friendly schools and thus to the promotion of education for all.

This interagency initiative has identified a core group of activities, each already recommended by the participating agencies, that captures the best practices from programme experiences. Focusing initially on these activities will allow concerted action by the participating agencies, and will ensure consistent advice to country programmes and projects. Because of the focused and collaborative nature of this approach, it will increase the number of countries able to implement school health components of child-friendly school reforms, and help ensure that these programmes go to scale. The focused actions are seen as a starting point to which other interventions may be added as appropriate.

The actions also contribute to existing agency initiatives. They are an essential component of the "health promoting schools" initiative of WHO and of global efforts by UNICEF, UNESCO and the World Bank to make schools effective as well as healthy, hygienic and safe. Overall, the inter-agency action is perceived as Focusing Resources on Effective School Health and giving a FRESH Start to improving the quality and equity of education.

Focusing Resources on the School-Age Child

A child's ability to attain her or his full potential is directly related to the synergistic effect of good health, good nutrition and appropriate education. Good health and good education are not only ends in themselves, but also means which provide individuals with the chance to lead productive and satisfying lives. School health is an investment in a country's future and in the capacity of its people to thrive economically and as a society. An effective school health, hygiene and nutrition programme offers many benefits:

Responds to a new need
The success of child survival programmes and the greater efforts by many governments and communities to expand basic education coverage have resulted both in a greater number of school-age children and in a greater proportion of these children attending school. In many countries, targeted education programmes have ensured that many of these new entrants are girls for whom good health is especially important. Thus, the school is now a key setting where the health and education sectors can jointly take action to improve and sustain the health, nutrition and education of children previously beyond reach.

Increases the efficacy of other investments in child development
School health programmes are the essential sequel and complement to early childhood care and development programmes. Increasing numbers of countries have programmes that ensure that a child enters a school fit, well and ready to learn. But the school age child continues to be at risk of ill health throughout the years of schooling. Good health at school age is essential 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. Furthermore, school health programmes can help ensure that the children who enter school without benefit of early development programmes receive the attention they may need to take full advantage of their educational opportunity.

Ensures better educational outcomes
Although school children have a lower mortality rate than infants, they do suffer from highly prevalent conditions that can adversely affect their development. Micronutrient deficiencies, common parasitic infections, poor vision and hearing, and disability can have a detrimental effect on school enrolment and attendance, and on cognition and educational achievement. In older children, avoidance of risky behaviours can reduce dropping out due, for example, to early pregnancy. Ensuring good health at school-age can boost school enrolment and attendance, reduce the need for repetition and increase educational attainment, while good health practices can promote reproductive health and help limit the spread of HIV/AIDS.

Achieves greater social equity
As a result of universal basic education strategies, some of the most disadvantaged children - girls, the rural poor, children with disabilities - are for the first time having access to school. But their ability to attend school and to learn whilst there is compromised by poor health. These are the children who will benefit most from health interventions, since they are likely to show the greatest improvements in attendance and learning achievement. School health programmes can thus help modify the effects of socioeconomic and gender-related inequities.

Is a highly cost effective strategy
School health programmes help link the resources of the health, education, nutrition, and sanitation sectors 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 accessibility of school health programmes to a large proportion of each nation's population, staff as well as students, contributes to the low cost of programmes. The high effectiveness of these programmes is a consequence of the synergy between the health benefit and the educational benefit. The effectiveness is measurable in terms not only of improved health and nutrition, but also of improved educational outcomes, reduced wastage, less repetition and generally enhanced returns on educational investments.

The Basic Framework for an Effective School Health and Nutrition Programme

The framework described here is the starting point for developing an effective school health component in broader efforts to achieve more effective, child-friendly schools. Much more could be done, but if all schools implement these four interventions there would be a significant immediate benefit, and a basis for future expansion. In particular, the aim is to focus on interventions that are feasible to implement even in the most resource-poor schools and in hard-to-reach rural areas as well as in accessible urban areas, and that promote learning through improved health and nutrition. These are actions known to be effective, and actively endorsed by all the supporting agencies: this is a framework from which individual countries will develop their own strategy to match local needs.

Core framework for action: four components that should be made available together, in all schools.

(i) 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 health policies should go beyond this to ensure a safe and secure physical environment and a positive psycho-social environment, and should address issues such as abuse of students, sexual harassment, school violence, and bullying. By guaranteeing the further education of pregnant schoolgirls and young mothers, school health policies will 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 to fight against reasons that girls withdraw or are 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, and teachers, children, and parents at the school level.
(ii) Provision of safe water and sanitation - the essential first steps towards a healthy learning environment. The school environment may damage the health and nutritional status of school children, 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 health and hygiene messages, and act as an example to both students and the wider community. This in turn can lead to a demand for similar facilities from the community. Sound construction policies will help ensure that facilities address issues such as gender access and privacy. Separate facilities for girls, particularly adolescent girls, are an important contributing factor to reducing dropout at menses and even before. Sound maintenance policies will help ensure the continuing safe use of these facilities.
(iii) Skills based health 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 physical health to include psycho-social and environmental health issues. Changes in social and behavioural factors have given greater prominence to such health- related issues as HIV/AIDS, early pregnancy, injuries, violence and tobacco and substance use. Unhealthy social and behavioural factors not only influence lifestyles, health and nutrition, but also hinder education opportunities for a growing number of school-age children and adolescents. The development of attitudes related to gender equity and respect between girls and boys, and the development of specific skills, such as dealing with peer pressure, are central to effective skills-based health education and positive psycho-social environments. 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.
(iv) School based health and nutrition services 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. For example, micronutrient deficiencies and worm infections may be effectively dealt with by infrequent (six-monthly or annual) oral treatment; changing the timing of meals, or providing a snack to address short term hunger during school - an important constraint on learning - can contribute to school performance; and providing spectacles will allow some children to fully participate in class for the first time.

Supporting Strategies

Several Strategies can support the implementation of the above components of FRESH:

(i) Effective partnerships between teachers and health workers and between the education and health sectors The success of school health programmes demands an effective partnership between Ministries of Education and Health, and between teachers and health workers. The health sector retains the responsibility for the health of children, but the education sector is responsible for implementing, and often funding, school based programmes. These sectors need to identify respective responsibilities and present coordinated action to improve health and learning outcomes for children.
(ii) Effective community partnerships Promoting a positive interaction between the school and the community is fundamental to the success and sustainability of any school improvement process. Community partnerships engender a sense of collaboration, commitment and communal ownership. Such partnerships also build public awareness and strengthen demand. Within the school health component of such improvement processes, parental support and cooperation allow education about health to be shared and reinforced at home. The involvement of the broader community (e.g. the private sector, community organizations and women's groups) can enhance and reinforce school health promotion and resources. These partnerships, which should work together to make schools more child-friendly, can jointly identify health issues that need to be addressed through the school and then help design and manage activities to address such issues.
(iii) Pupil awareness and participation. Children must be important participants in all aspects of school health programmes, and not simply the beneficiaries. Children who participate in health policy development and implementation; efforts to create a safer and more sanitary environment; in health promotion aimed at their parents, other children, and community members; and in school health services, learn about health by doing. This is an effective way to help young people acquire the knowledge, attitudes, values and skills needed to adopt healthy lifestyles and to support health and Education for All.