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The findings > Thematic Studies> School Health and Nutrition>Part 2 >cont. 4
  Country EFA reports
  Regional Frameworks for Action
Chapter V: Conceptual Frameworks: The Principles that Drive Action
A Historical Perspective of the School Health Field
Since the World Conference on Education for All in Jomtien, a major accomplishment has been the development of conceptual frameworks or unifying principles for school health policies and programs. These frameworks have also served as a catalyst to mobilize partnerships across sectors at all levels. In addition to the frameworks developed by U.N. agencies and a few other international organizations, significant and noteworthy activity was also conducted by frontline grassroot organizations in the past decade (Chandra-Mouli, 2000).
This chapter describes some of the major conceptual frameworks that have influenced the school health and nutrition agenda over the past decade. Frameworks developed in the 1990s include the concept of the Health-Promoting School (stimulated by the Ottawa Charter, 1986, and advanced by the Council of Europe, the Commission of the European Communities, and WHO/European office and WHO headquarters); the Child-Friendly School (UNICEF); the Basic Cost-Effective Public Health Package (World Bank and the Partnership for Child Development, University of Oxford); and Active Learning Capacity (Levinger, EDC, for USAID and UNDP). One framework, FRESH (Focusing Resources on Effective School Health (WHO, UNICEF, UNESCO, World Bank), was launched jointly at the EFA Conference in Senegal in April 2000.
The Framework of the Health-Promoting School
The concept of the Health-Promoting School (HPS) started in Europe. It is based on public health theory and builds on the Ottawa Charter of Health Promotion (1986), which recognized that "health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. 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 ensuring that the society one lives in creates conditions that allow the attainment of health by all its members" (WHO, 1986). The European Regional Office of WHO, the Council of Europe, and the Commission of the European Communities first widely promoted the concept of the Health Promoting School. The aim was to achieve healthy lifestyles for the total school population by developing environments conducive to the promotion of health. The HPS concept extended beyond school health education to a broader array of complementary interventions.

The earliest descriptions of the HPS, then called "the Healthy School," were developed during the first major conference of all the European nations on school health promotion in Scotland in 1986. The model, described in a report by Young and Williams, featured an overarching policy and three essential coordinated components: instruction, health services, and a healthy school environment-both physical and psychosocial (Young, 2000). A similar concept, the Eight Component Model, was developed in the United States by Allensworth and Kolbe in an effort to explore whether the concept of the school health program should be expanded. If coordinated, the following eight components of the model could have complementary if not synergistic effects (Kolbe, 1986; Allensworth & Kolbe, 1987):

school health services

school health education

school health environment

integrated school and community health promotion efforts

school physical education

school food service · school counseling

school health promotion programs for faculty and staff

In the 1990s both of these frameworks guided many policy decisions and programmatic efforts throughout Europe and the former Soviet Union and in the United States. As documents and program descriptions were published, interest grew among international and national health and education workers to apply them to the needs of a broad range of countries.
To gain a thorough understanding of the status of school health worldwide and prepare recommendations for improving health through schools, in 1994-95 WHO convened an Expert Committee. EDC synthesized findings from hundreds of evaluation research and feeder papers written by WHO's staff and experts around the world. This initiative produced the following four documents, published by WHO: The Status of School Health; Improving School Health Programs: Barriers and Strategies; Research to Improve Implementation and Effectiveness of School Health Programs; and Promoting Health through Schools.
The Expert Committee concluded that research in both developing and developed countries demonstrates that school health programs can simultaneously reduce common health problems, increase the efficiency of the educational system, and further public health, education, and social and economic development in all nations. The committee made ten recommendations to improve health through schools worldwide (see box).

Recommendations of the WHO Expert Committee on Comprehensive School Health Education and Promotion (1995)

1. Investment in schooling must be improved and expanded.

2. The full educational participation of girls must be expanded.

3. Every school must provide a safe learning environment for students and a safe workplace for staff.

4. Every school must enable children and adolescents at all levels to learn critical health and life skills.

5. Every school must more effectively serve as an entry point for health promotion and a location for health intervention.

6. Policies, legislation, and guidelines must be developed to ensure the identification, allocation, mobilization, and coordination of resources at the local, national, and international levels to support school health.

7. Teachers and school staff must be properly valued and provided with the necessary support to enable them to promote health.

8. The community and the school must work together to support health and education.

9. School health programs must be well designed, monitored, and evaluated to ensure their successful implementation and outcomes.

10. International support must be further developed to enhance the ability of Member States, local communities, and schools to promote health and education.


Following the Expert Committee's meeting and report in 1995, WHO launched its Global School Health Initiative to support schools to become Health-Promoting Schools. Although definitions will vary among regions, countries, and schools according to need and circumstance, a HPS can be characterized as a school that is constantly strengthening its capacity as a healthy setting for living, learning, and working.

A Health-Promoting School:

WHO headquarters' Global School Health Initiative uses four strategies to disseminate this framework:

Consolidating research and expert opinion to describe the nature and effectiveness of school health programs (WHO, 1996a; WHO, 1996b; WHO, 1996c; WHO, 1996d; WHO, 1997a).

Building capacity to advocate for the creation of Health-Promoting Schools (HPS) and to apply the components of a HPS to priority health issues, including helminth infections, violence, nutrition, tobacco use, and HIV/STI (WHO, forthcoming; WHO, 1997c; WHO, 1998b; WHO, 1998c; WHO, 1998d; WHO, 1998 draft).

Strengthening collaboration between the ministries of education and health and other relevant organizations and national capacities to assess, plan, and implement policies and programs to improve health through schools (WHO, 1998e; Vince-Whitman et al., 1997).

Creating networks and alliances, including regional networks for the development of Health-Promoting Schools and international alliances, such as among WHO, EI, UNESCO, UNAIDS, CDC, and EDC to strengthen the capacities of teachers' unions to prevent HIV/STI (WHO, n.d.; WHO, n.d.; EI, 1998).

These strategies have been implemented in collaboration with other relevant programs and departments within WHO, including the WHO Regional Offices, and with international agencies that are interested in promoting the development of Health-Promoting Schools, including Education International (EI), a trade organization of about 25 million teachers worldwide, and Child-to-Child Trust. The European Network of Health-Promoting Schools, for example, has since 1990 enrolled more than 500 pilot schools with 400,000 students in 37 countries in Europe and the former Soviet Union (European Commission et al., 1996).
The Framework of the Child-Friendly School
Based on the Jomtien documents and a number of other developments in the field of children's rights, UNICEF has recently developed a framework of rights-based, child-friendly educational systems and schools that are characterized by being "healthy for children, effective with children, protective of children, and involved with families and communities-and children" (Shaeffer, 1999).
This framework builds on the Jomtien conference's proclamation that "education is a fundamental right for all people, women and men, of all ages, throughout our world." Relevant to health, the declaration went on to say that "education can help ensure a safer, healthier, more prosperous and environmentally sound world" (Inter-Agency Commission, 1990a).
UNICEF's framework was also inspired by the Convention on the Rights of the Child, held in 1989, which set the stage by acknowledging that children's rights require special protection for the purpose of the general improvement of their conditions and for their development and education.
UNICEF's framework broadly defines core components that characterize a child-friendly school, each component incorporating factors concerning education, health, and human rights.

In a Child-Friendly School:

The school is a significant personal and social environment in the lives of its students. A child-friendly school ensures every child an environment that is physically safe, emotionally secure, and psychologically enabling.

Teachers are the single most important factor in creating an effective and inclusive classroom.Child-friendly schools are teacher-friendly, supporting, encouraging, and facilitating teachers toward being motivated, capable, self-confident, and consistently available.

Children are natural learners, but this capacity to learn can be undermined and sometimes destroyed. A child-friendly school recognizes, encourages, and supports children's growing capacities as learners by providing a school culture, teaching behaviors, and curriculum content that are focused on learning and the learner.

The ability of a school to be and to call itself child-friendly is directly linked to the support, participation, and collaboration it receives from families.

Child-friendly schools have a key role to play in ensuring that children's rights are reflected throughout the education system, just as education systems must ensure that schools have the resources to act on behalf of all children.

The rights of children as articulated in the CRC are indivisible. They all apply, all of the time, to all children. Schools and educational systems have a role in ensuring that children's rights are reflected throughout a country's governance community. Child-friendliness is a broad public policy matter (Bernard, 1999 draft).

Child-friendly schools aim to develop a learning environment in which children are motivated and able to learn. Staff members are friendly and welcoming to children and attend to all their health and safety needs. WHO supports the framework of the Child-Friendly School by helping schools become "health-promoting" as an essential step toward becoming "child-friendly."
The Framework of the Basic Cost-Effective Public Health Package
The concept that schools are in a position to deliver a basic package of health services to students has been widely acknowledged during the 1990s. The appropriate level of services for the schools to offer depends on each country's operational and financial resources (Del Rosso & Marek, 1996).
A 1993 World Bank analysis concluded that most regions of the world could greatly benefit by implementing a limited package of five cost-effective public health elements. This package could reduce 8% of the burden of disease in low-income countries for $4 per capita and could reduce 4% of the burden in middle-income countries for $7 per capita (World Bank, 1993).

The five elements are:

An extended program on immunization

School health programs to treat worm infections and micronutrient deficiencies and to provide health education

Programs to increase public knowledge about family planning and nutrition, self-care or indications for seeking care, and vector control and disease surveillance activities

Programs to reduce the consumption of tobacco, alcohol, and other drugs ·

AIDS-prevention programs with a strong component on other sexually transmitted diseases (World Bank, 1993)

The WHO Expert Committee on Comprehensive School Health Education and Promotion commented on this basic package that "[al]though school health programs are explicitly mentioned in only one of the above elements, for a large portion of the world's population, schools could efficiently provide all five elements of the recommended package" (WHO, 1997a).
The Partnership for Child Development, UNICEF, the World Bank, and other agencies have used this framework to guide program development in countries around the world. In the state of São Paulo, Brazil, a World Bank loan is helping to provide a broad range of school-based services including feeding programs, health and nutrition screening of schoolchildren, nutrition and health education in the school curriculum, and school-based programs for iron and vitamin A supplementation. A more limited package of services with low-cost, easy to implement interventions is applied in Guinea, where almost no prior nutrition and health programs for school-age children existed. The elements of a school-based health package in Guinea initially include a deworming program and iron and iodine supplementation, accompanied by education in health and hygiene (Del Rosso & Marek, 1996). Carefully monitored school-based health and nutrition programs implemented by the Partnership for Child Development in Ghana, Tanzania, India, and Indonesia have now shown that the education sector is capable of delivering a simple health package (health education, anthelmintics, and micronutrients) to large numbers of schoolchildren (50,000 to 3 million) without the creation of specific infrastructures. These experiences suggest that the school system can contribute to health delivery as long as the package is simple, demands little school time, and is perceived as appropriate to local needs (PCD, 1997).
The Framework of the Child's Active Learning Capacity
In the early 1990s, in support of the mission to achieve Education for All, Beryl Levinger of EDC wrote for USAID and UNDP about the need to concentrate on improving a child's "active learning capacity" (ALC). Consistent with theories in education and the social sciences, she defined ALC as "the child's ability to interact with and take optimal advantage of the full complement of resources offered by any formal or informal learning environment" (Levinger, 1994). The importance of this definition lies in its belief that to maximize learning, a child must be psychologically, emotionally, and physically well, able to concentrate on and participate actively in the learning process, able to pay attention and concentrate on tasks, and missing only a few days of school for illness or other reasons. The ALC framework focuses on improving the quality of the child as one of the most important factors in achieving the goals of Education for All.
This framework includes three primary variables: health and nutrition status, hunger level, and psychosocial support. Health and nutrition status refers to both current and prior physical or mental conditions, such as height for age, sensory abilities, nutritional status, and helminthic infections that influence a child's ability to take optimal advantage of learning resources and opportunities. Temporary hunger, especially if a child is malnourished, contributes to a child's distractibility, inattentiveness to environmental stimuli, and adaptive behaviors of passivity and inactivity, all of which impinge on the development of a child's ALC. Psychosocial support encompasses the degree to which parents, caretakers, community leaders, and other significant adults, community institutions, as well as values and norms encourage a child's independence and inquisitiveness and support expectations that favor overall learning as well as formal schooling.
Three variables are considered secondary in determining active learning capacity: prior learning experience, a child's learning receptiveness, and a child's aptitude for learning. Prior learning experience refers to a child's exposure to formal and informal situations conducive to acquiring new knowledge and skills, such as preschool programs. Learning receptiveness refers to a child's motivation and attention, which are influenced by health status and hunger level, as well as by the quality of the child-caretaker relationship. Aptitude relates to the time a child needs to learn a particular task, attend to stimuli, and concentrate.
The ALC framework represents a dynamic portrayal of the complex interplay among the determinants of educational outcomes, capturing the high degree of influence that health, nutrition, sensory impairment, and temporary hunger exert on the quality of the child and hence on the child's learning outcomes (Levinger, 1994).
This framework was used widely by the South African Active Learning Network, a group of NGOs, to develop materials, protocols, and broker links between the health and education sectors. Among the entities that participated were CIDA, WHO, UNICEF, the World Bank, and USAID. Many of the Network's activities were designed to promote the ALC model or to further its application.
The Importance of Frameworks in Collaboration
Some of the most important lessons learned in recent years are the need for multisectoral collaboration and cooperation in order to move toward the health and educational goals of Education for All. "Indicators of a favorable policy setting include a demonstrated ability to secure interministerial cooperation; a coordinated, intersectoral approach to human development; a history of support for community-based health and education programs; and a commitment at the highest political levels to programs that address questions of equity as well as growth" (Levinger, 1994).
For instance, during the past decade, the World Bank coordinated information to enhance the quality of school health and nutrition programs through its International School Health Initiative. Its experiences of good practice suggest that school-based health and nutrition programs should be simple and locally relevant. The following items have been suggested to contribute to such programs: life skills training, health services, school snacks fortified with micronutrients, an exemplary school environment, equitable school health policies, and strategies beyond the school (Dolan, 1999).
A shared framework and strategy for action often form the foundation of successful collaboration. Even when there is no one unifying framework, collaboration is more likely when the participants at least understand and respect one another's language, methods, and frameworks. In either case, the partners can identify their unique strengths in the context of a framework and channel their specific contributions to move a shared agenda forward.
As the decade draws to a close, some of the major leaders and change agents at the world level are coming together to discuss how they might build on the frameworks since Jomtien and collaborate on a common framework for school health, such as FRESH. Such collaboration may allow partners to harness their considerable human and financial resources more effectively to address the health needs of a greater number of children and adolescents in schools around the world.
The FRESH Framework: A Concerted Effort to Focus Resources on Effective School Health
A framework proposed jointly by WHO, UNICEF, UNESCO, and the World Bank suggests that there is a core group of cost-effective components that could form the basis for intensified and joint action. These agencies are now developing a partnership to Focusing Resources on Effective School Health (FRESH), launching it at the Education for All Conference in Senegal in April 2000.
Each component of the framework stresses that a young person's health is one of the many important factors that must be adequately addressed to achieve any country's educational goals. As Bundy comments, "Good health and good education are not ends in themselves, but rather 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" (Bundy, 1999).

Building on the frameworks developed in the past decade, this shared view serves as a basis for an effective school health and nutrition program. Its four components are intended to be made available together in all schools.

Health-related policies in schools: Health policies in schools, including policies for skills-based health education and the provision of some health services, can help promote the overall health, hygiene, and nutrition of children. Good health policies should also ensure a safe and secure physical environment and a positive psychosocial environment and should address issues such as the abuse of students, sexual harassment, school violence, and bullying. By guaranteeing the continued 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 combat the reasons that girls withdraw or are withdrawn from schools. Policies regarding the health practices of teachers and students can reinforce health education by requiring that teachers do not smoke at school and thus act as positive role models for their students. The process of developing and agreeing on 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.

Safe water and sanitation facilities: It is a realistic goal in most countries to ensure that all schools have access to clean water and sanitation. Without clean water and adequate sanitation, hygiene education is meaningless. The school environment may even damage the health and nutritional status of its children if it increases their exposure to hazards such as infectious diseases carried by the water supply. By providing clean water and sanitation, schools can reinforce the health and hygiene messages and act as an example to both students and the wider community. This in turn can lead to a demand from the community for similar facilities. Sound construction policies will help ensure that facilities address issues such as gender access and privacy. Separate facilities for girls, particularly adolescents, are important in reducing dropout at menses and even before. Sound maintenance policies will help ensure the continuing safe use of these facilities.

Skills-based health education: This approach to health, hygiene, and nutrition education focuses on the development of knowledge, attitudes, values, and life skills needed to make and act on the most appropriate and positive decisions concerning health. Health in this context extends beyond the physical to include psychosocial and environmental health issues. The development of attitudes toward gender equity and respect between girls and boys and the development of specific skills, such as dealing with peer pressure, are central to both an effective skills-based health education and positive psychosocial environments. With these skills, individuals are more likely to adopt and sustain a healthy lifestyle during their schooling and for the rest of their lives.

School-based health and nutrition services: Schools can effectively deliver some health and nutritional services as long as the services are simple, safe, and familiar and address problems that are prevalent and recognized as important in the community. If these criteria are met, then the community sees the teacher and school more positively, and teachers see themselves as playing important roles. For example, micronutrient deficiencies and worm infections may be effectively dealt with by infrequent (half yearly or annual) oral treatment; changing the timing of meals or providing a snack to address short-term hunger during the school day¾an important constraint on learning¾can contribute to school performance; and providing eyeglasses will allow some children to participate in class fully for the first time.

Within this framework, these four components are intended to be supported by effective partnerships between teachers and health workers, effective community partnerships, and pupil awareness and participation (WHO, UNESCO, UNICEF, World Bank, to be presented at EFA 2000, Dakar).
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