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The findings > Thematic Studies> School Health and Nutrition>Part 2 >cont. 5
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Chapter VI: Major Global Trends: Developments since Jomtien
 
 
Chapter IV described the status of the school health field leading up to Jomtien. This chapter shows some of the major trends, events, and activities that have happened over the last ten years. With a scope as broad as a decade and a platform as enormous as the world, only selected examples are given. Figure III, in the appendix, lists selected online resources for school health and additional information. Figure IV provides examples of major trends and activities, barriers, and future actions for the field of school health across regions and countries.
 

Several major global trends over the past decade have dramatically influenced the scope and direction of school health work:

1. The AIDS pandemic stimulated a new demand and urgency for school health.

2. There was a gradual move from individual to multiple strategies and to integrated and coordinated approaches to school health programs.

3. New mechanisms for multi-sectoral collaboration have emerged.

4. Student and community participation has been an important factor in promoting school health.

5. Skills-based methods for health education have gained recognition and greater use.

6. The documentation and dissemination of evidence of effectiveness have increased.

7. New tools for assessment, planning, and monitoring have been tested.

8. Both, donor recognition of the field and investment have increased.

9. International conferences have addressed school health.

10. Various barriers still exist that can hinder future progress toward effective and sustained school health and nutrition interventions.

 
To explain more fully:
 
A defining characteristic of the 1990s has been the influence of the HIV/AIDS pandemic on school health policies and programs. The tragedy of this disease left many children as orphans and many teachers and students dying. While this pandemic closed the school door to many children and teachers affected or infected by it, it also opened many doors to school health programs (Dick, 1999).
 

Because education to increase protective behaviors is one of the few measures available to prevent HIV, and because prevention ideally should begin before the onset of sexual activity or alcohol and drug use, schools became a very important setting for delivering life-saving interventions to children and adolescents worldwide.

As educators and health workers began to plan and implement school-based efforts to prevent HIV infection, many in the field were asking what strategies were most likely to motivate people to adopt protective behaviors. Such questioning, in the face of the threat of HIV infection, led to reviews of lessons learned from health education, sex education, family life, and reproductive health education; increased calls for the implementation and improvement of such programs; the innovative use of skills-based methods; the cross-fertilization of ideas and strategies among experts; and the involvement of young people in designing and delivering programs. UNESCO, for example, launched a global Program of Education for the Prevention of AIDS, which focuses on integrating HIV/AIDS education into school curricula. Its main goal is to put in place large national programs that draw on the experiences of other projects and programs. UNESCO's resource centers disseminate numerous materials and documents on HIV/AIDS education, along with seminars and training for ministerial staff and teachers (Dolan, 1999).
 
Since Jomtien, the following types of activities illustrate how the complex and sensitive issues surrounding HIV/AIDS served as an impetus for strengthening national, regional, and global efforts to improve health through schools:
 
On a national level: In Zimbabwe, which has one of the highest rates of AIDS cases on the African continent, the Ministry of Education and Culture initiated an AIDS Action Program targeting students and teachers in grades 4-7. More than 2,000 teachers have been trained to use, not only specified AIDS education materials, but also participatory life skills methods. National programs fostered by UNICEF and focusing on life skills have strengthened school health efforts by helping teachers: explore their own attitudes and values about health, establish an open and positive classroom climate, place education about HIV/AIDS in the context of a general program on health, personal development, and living skills, and use positive approaches that emphasize an awareness of values, assertiveness, and other relationship skills (Gachuhi, 1999).
 

On a regional level: In 1993, participants in the Inter-Country Consultative Meeting on Comprehensive School Health Education, convened by the South East Asia Regional Office of WHO, recommended that in view of the physical, social, and psychological needs of children, adolescents, and youth and the emerging health problems such as AIDS/STD, drug and alcohol and tobacco use, comprehensive school health education be given the status of a separate subject in the school curriculum, in addition to being integrated into other relevant subject areas. Furthermore, the participants recommended that because comprehensive school health education cannot be implemented effectively by teachers without appropriate training, every member country in the South East Asia Region should give priority to such training, including adequate financial support for strengthening pre-service and in-service training in health for teachers (WHO, 1993).

On a global level: In 1995, EI, WHO, UNESCO, and UNAIDS, in collaboration with CDC and EDC, created an alliance to increase the interest and involvement of teachers' unions in HIV/AIDS prevention and in strengthening school health programs. In July 1998, at EI's Second World Congress, teachers' unions from around the world adopted a resolution on Health Promotion and School Health. It calls on EI's member organizations to:

Play an active role in the elaboration of school health education policies in close collaboration with the ministries of education and health.

Take more account of the crucial role that the school system and workers in education can play through health education to prevent HIV/AIDS and STDS and drug abuse.

Become more involved at every stage of the conception, implementation, and evaluation of school health programs.

Take action to ensure that all educational workers receive initial and in-service training, enabling them to promote health and health education. · Combat all forms of discrimination and exclusion affecting students or workers in education affected by HIV/AIDS or excluded because of their genetic characteristics.

Establish or develop contacts with parents and health professionals at the local or national level.

Commit themselves, especially in the framework of the Health Promoting School, to make the school a healthy place that offers a reliable infrastructure to guarantee protection from diseases, violence, and harmful substances.

 
 
Such actions show an increased recognition of the need for and value of working collaboratively to address HIV/AIDS while also improving school-based efforts that address other issues affecting health and learning. For instance, the use of tobacco and other psychoactive substances has also stimulated interest and action in the field of school health during the past decade, especially in the Eastern Mediterranean and the Western Pacific regions. Often, however, efforts were implemented as separate, vertical programs (Chandra-Mouli, 2000).
 
2. There was a gradual move from individual to multiple strategies and to integrated and coordinated approaches to health education.
 
During the 1990s, frameworks evolved that included multiple strategies-rather than individual approaches-to promote health and nutrition through the schools. For instance, WHO's Health-Promoting School model and its supporting tools (such as Local Action: Creating Health-Promoting Schools) involve various participants at the school level to foster health and learning with all the measures at their disposal. In UNICEF's Child-Friendly Schools Framework, the school culture, teaching behaviors, and curricula content are all conducive to learning and learners.
 
In the United States, the book Health Is Academic outlines the concept and components of coordinated school health programs (http://www.edc.org/ HealthIsAcademic). It was developed by EDC, with funding by CDC/DASH, and reviewed by more than 300 professionals before it was published in 1998. This book and other efforts have had a marked effect on moving national school programs toward a coordinated approach to school health. The tendency toward more integrated and coordinated approaches to school health is likely to continue and will balance content from traditional disciplines. Health education can be coordinated with or integrated into other subjects such as science, technology, physical education, home economics, and social studies.
 

There are some notable examples of implementing coordinated school health initiatives with multiple strategies, which can both inspire and guide the field in the decade to come. For instance:

The Ministry of Health in Guinea, in collaboration with other agencies, developed the following components for their Equity and School Improvement Project (PASE), using data from baseline studies and the World Bank's International School Health Initiative's planning framework: teacher development in the areas of helminth treatments, health education, and referral for health services; and health services in the schools to include antihelminth drugs, iodine, and iron supplementation. Central to this project is community partnership and partnership across sectors. A 1997 process evaluation study revealed that the program was viewed positively by 99.3% of children and 100% of schools and had an impact on enrollment, re-enrollment, and increased participation by parents. Expansions are planned to include antimalarials, vaccination, reproductive health, and HIV/AIDS/STD education, campaigns to combat substance abuse, and measures to reduce hunger (PCD, 1999g).

The county of Lianjiang, China, launched a comprehensive approach to creating Health-Promoting Schools in rural China, starting with deworming. The project included guiding policy, collecting baseline data, training staff, mobilizing the community, two intervals of deworming services, improving the latrines and safe water supply, and related health education activities. Evaluations of this approach showed reductions in helminthic infections and egg contamination in school environments and positive changes in the students' knowledge and preventive behaviors (Xu et al., 2000).

A U.S. high school set up integrated services that included individual and family counseling, primary and preventive health services, drug and alcohol abuse counseling, crisis intervention, employment counseling, training, and placement, summer and part-time job development, recreational activities, and referrals to health and social services. During the first two years of the program, the number of births among the students in this school dropped from 20 to 1, dropouts were reduced from 73 to 24, and suspensions were reduced from 322 to 78 (Knowlton & Tetelman, 1994).

 
3. New mechanisms for multi-sectoral collaboration have emerged.
 
During the 1990s it became increasingly apparent that in order for schools to improve health, international, national, provincial, and local agencies, education and health professionals and parents and communities will need to work together on behalf of young people (Kolbe et al., 2000). A recent survey of donors and agencies found that "there is a move towards inter-agency school health planning, monitoring and evaluation, particularly in the U.N.. This reflects a move by the U.N. system and bilaterals towards a sector-wide approach to funding, and away from a project approach" (Dolan, 1999). For instance, a situation analysis that includes assessments of adolescents' needs and responses was developed as an interagency activity by UNDP, UNESCO, UNFPA, WHO, and PCD and has been evaluated by WHO in Ghana, Zimbabwe, Botswana, Uganda, and Kenya (Dolan, 1999). The World Bank's International School Health Initiative has helped to create global partnerships that focus on a common school health agenda (Bundy, 2000). Agencies and donors have also expressed interest in a school health Web site and mailing list, as is currently being developed by PCD with the World Bank, which will provide a vehicle for greater collaboration (Dolan, 1999).
 
The Partnership for Child Development has established programs that emphasize the development of national collaborations as a part of locally managed programs, the core of which is the essential partnership between the health and education sectors. There are now PCD research programs or activities in more than 14 countries around the world that are supported by a broad range of international agencies (UNDP, WHO, UNICEF, World Bank), bilateral agencies (USAID, UKDFID), and charities (Rockefeller Foundation, Edna McConnell Clark Foundation, James S. McDonnell Foundation, Wellcome Trust, and Save the Children Federation). The Partnership was set up to develop the intersectoral collaborations necessary to establish or strengthen school health programs. This international initiative helps to provide technical assistance and support so that low-income countries can monitor and evaluate the costs, processes, and impact of these programs (PCD, 1999f).
 
A major new global partner is Education International. Established in 1993, EI represents more than 25 million teachers and workers in the education sector, and more than 250 teachers' unions in 150 countries are affiliated with EI. EI has adopted resolutions to promote health and nutrition for its membership and has also participated extensively with WHO, UNAIDS, UNESCO, and HHD/EDC in providing professional development on health promotion for members and HIV prevention initiatives.
 
Stimulated by WHO headquarters, WHO regional offices, and others, networks have emerged as a means of communication and technical support. Regionally, networks of persons responsible for school health from both the education and health sectors have been created to share experience and foster collaboration across sectors. One of these networks is the European Network of Health-Promoting Schools, a consolidating initiative between the health and education sectors (European Commission et al., 1996). WHO's Mega Country Health Promotion Network serves as a new mechanism to foster cooperation between the ministries of education and health in the 11 most populous countries, which face the common problem of size. In the E-9 Initiative, sponsored by UNESCO, UNICEF, and UNFPA, leaders of the 9 most populous developing countries pledged to universalize primary education and reduce illiteracy in their respective countries. However, such intra- and intercountry networks do not yet involve every country..
 
On a national level, collaboration between the health and education sectors has been critical to program development. National intersectoral coordinating committees have been formed in a number of countries, including Samoa, Cambodia, Indonesia, and Laos (Lin, 1999). In Viet Nam, the School Health Insurance was introduced in 1995 as a joint effort of the Ministry of Health and the Ministry of Education and Training. This collaborative achievement enabled the government to respond to two major concerns of Viet Namese parents: the protection of their families against adverse consequences of their children's ill health, and the creation of school conditions and programs that are conducive to health and that help children and their families stay healthy (Carrin et al., 1999).
 
4. Student and community participation has been an important factor in promoting school health.
 
During the 1990s, many publications and actions have recognized and strongly supported youth and community involvement as important for effective school health and nutrition programs. WHO's Adolescent Health Program concluded that youth involvement ensures project relevance, acceptability, dedication to project objectives, long-term effectiveness, and personal development for the young participants (WHO, 1997d; WHO/UNFPA/UNICEF, 1995). A paper prepared for the Conference on Comprehensive Health of Adolescents and Youth in Latin America and the Caribbean in 1996 states that "involvement of youth is critical at every step along the way" (Burt, 1998).
 
The European Network of Health-Promoting Schools (ENHPS) has published many case studies that show how students have been involved in planning, implementing, and evaluating various school projects. In Gandrup school in Denmark, students have been involved in planning. The pupils, who claimed that they learn more when they are able to influence the choice of subjects, discussed the WHO definition of health and then identified conditions they wished to change in their school life, the community, or their own lives (Jensen, 1997a). In another project at the same school, students were involved in implementing programs. Fourth-grade pupils taught second-graders. This project showed that "pupil participation is a key prerequisite of sustaining their involvement and motivation" (Jensen, 1997b). In a school in Finland, students were actively involved in the evaluation of a school democracy project in which they evaluate themselves, their actions, and their progress twice a year. "This is important to the young people because they can compare themselves with the prevailing norms and then decide themselves in which ways they want to improve or change." Feedback from teachers, pupils, and others has proved that this project is worth continuing (Poentinen, 1998).
 
Family and community involvement has also been strongly supported during the past decade. A recent U.N. study included community and family involvement as a vital factor for "programs that work." Community members must be recognized as central actors rather than passive beneficiaries. In Tanzania, for instance, severe malnutrition disappeared during a program whose feature was growth monitoring in the community (UNICEF, 1998).
 
Active community participation has also played an increasingly prominent role in effective collaboration. An extensive analysis of the progress in the development of education in Africa found that "the role of communities as providers of education is becoming more complex and more substantive. ... Communities are becoming involved in matters previously regarded as within the domain of professionals and ministries. Communities are currently involved in the recruitment of teachers, the negotiation of teacher salaries, teacher management (Guinea, Cameroon, Senegal, and Tchad), school management (Côte d'Ivoire, Zanzibar, and Tchad), the selection of school curricula (Zanzibar), school mapping (Côte d'Ivoire, Gambia), financial management (Madagascar, Tanzania), and the establishment and management of preschools (Zanzibar). There appears to be a partial shift of the locus of action and control from the central ministries to the communities" (ADEA, 1999, p. 64).
 
Local expertise is also indispensable to effective programs and to identifying and solving local problems. Africa, for example, has a wealth of community associations, including parent-teacher associations, that can channel community participation and responsibility. The early involvement of such organizations in developing a program maximizes the community's commitment and the program's sustainability. In Ghana, communities "revealed not only their interest in alleviating the health and nutrition problems of their school-age children but also a willingness to help pay for these services" (Del Rosso & Marek, 1996, p. 36).
 
5. Skills-based methods for health education have gained recognition and greater use.
 
Research has demonstrated the effectiveness of skills-based approaches in promoting healthy choices and in preventing or delaying risk behaviors. Such skills include refusal, communication, critical thinking, and other life skills. Interactive methods, which give young people in the classroom the opportunities to practice these skills with regard to important health issues, are the most critical factor in achieving success. Increasingly, schools are giving priority to teaching life skills. Numerous products have emerged to support skills-based approaches. Many countries (e.g., Zimbabwe, Cameroon, Colombia, Costa Rica) have carried out skills-based health education projects. Uganda, for example, launched a very well planned, comprehensive school health initiative. Along with creating a network of health educators at the district level for health education activities, skills-based health education was integrated into the basic science curriculum and also became part of the examination process (Hubley, 1998). In September 1999, the Pan American Health Organization convened a conference with Latin American and Caribbean countries to plan how to strengthen skills-based health education in the region.
 
6. The documentation and dissemination of evidence of effectiveness have increased.
 
The past ten years have seen an explosion in the number of documents published by international organizations to report on the effects of single interventions, such as treatments for intestinal worms or nutritional deficits to reduce health problems and improve learning. Others, such as Promoting Health Through Schools, Report of a WHO Expert Committee on Comprehensive School Health Education and Promotion (WHO, 1997a) and Class Action: Improving School Performance in the Developing World Through Better Health and Nutrition (Del Rosso & Marek, 1996), have synthesized the findings of hundreds of studies to inform and convince policy-makers and practitioners that the status of a child's health is a critical variable in achieving the goals of Education for All. One of the greatest innovations of the past decade is the use of the World Wide Web for global knowledge sharing. The Web, relatively untapped for school health in 1990, is broadly disseminating evidence of the best practices worldwide in timely and cost-effective ways. For instance, the Partnership for Child Development and the World Bank are currently developing a Web site and moderating an e-mail discussion list for donors, agencies, and governments in order to share school health-related experiences, research, programming, and related issues: http://www.ceid.ox.ac.uk/schoolhealth (Dolan, 1999).
 
7. New tools for assessment, planning, and monitoring have been tested.
 

Several tools have been pilot tested, including those for:

(1) Situational Analysis, developed by the Partnership for Child Development in collaboration with other agencies, including UNICEF, the Edna McConnel Clark Foundation, WHO, USAID, PAHO, and the World Bank (http://www.ceid.ox.uk/ schoolhealth/download%20documents.htm). The goal of the situational analysis is to guide the design and evaluation of school-based health and nutrition programs.

(2) Rapid Assessment and Action Planning Process (RAAPP), initiated by WHO, PAHO, HHD/EDC, EI, and national agencies in Indonesia, Bolivia, and Costa Rica. Consistent with the HPS framework, RAAPP includes instruments, data collection, analysis procedures, and strategic planning tools. Its purpose is to assess and strengthen a country's infrastructure to support school health programs (Vince-Whitman et al., 1997). Rapid Assessment Tools have also been used by various other WHO programs recently (e.g., WHO, n.d.).

(3) UNESCO/WHO Survey on National School Health Policies, administered by UNESCO in December 1999, includes items to assess which ministries are responsible for school health issues and the existence of national policies relating to the school environment, school health services, and the teaching of health in primary and secondary schools. Preliminary findings were presented at the World Education Forum 2000 (UNESCO, n.d.; Birdthistle, 2000)

(4) Health Behavior in School-Aged Children (HBSC), developed by WHO/EURO and adopted by more than 25 countries to monitor health and health-related behaviors and social influences on young people (Wold & Aar, 1990; Wold, 1993; http://www.uni-bielefeld.de/gesundhw/hbsc/intpub.html).

(5) Youth Risk Behavior Survey (YRBS), developed by the Division of Adolescent and School Health of the U.S. Centers for Disease Control and Prevention and piloted in more than 10 countries, including China and the Russian Federation. The YRBS collects data through schools that describes the prevalence of high-risk behaviors among young people (http://www.cdc.gov/nccdphp/dash/yrbs/index.htm). Its purpose is to monitor whether these behaviors change over time (Kolbe et al., 1993).

(6) The joint UNESCO-UNICEF International Assessment Survey Project helps countries to collect empirical data describing health-related learning outcomes and health-related teaching and learning conditions in schools. Two prototype instruments have been developed:

(1) Monitoring Learning Achievement (MLA), which has a specific section labeled "life skills" containing questions about health-related knowledge; and

(2) Conditions of Teaching and Learning (CTL), which contains questions about school facilities and health, safety, and security measures taken by schools. The surveys provide nationally representative data obtained from fourth-grade students (stratified random samples). They have been adapted and implemented in approximately 40 countries as part of the EFA 2000 assessment (Chinapah, 1997).

(7) School Health Policies and Programs Study (SHPPS), developed by the U.S. Centers for Disease Control and Prevention to monitor improvements in eight components of the school health program throughout the United States (http://www.cdc.gov/nccdphp/dash/shpps; Kolbe et al., 1995).

 
The use of each of these tools has been fairly limited. Still needed are instruments to monitor progress worldwide, based on common and comparable data items and data collection methods.
 
In the coming decade, FRESH partners plan to work collaboratively to strengthen the monitoring and evaluation of school health efforts, using and adapting the tools mentioned above.
 
8. Both, donor recognition of the field and investment have increased.
 

Donors and philanthropic agencies appear to have an increased commitment to providing financial and technical support for improving health through the schools. A survey of donor and agency support for school-based health and nutrition programs found that increased donor interest and investment in the health and nutrition of the school-age child was most apparent in the U.N. system but also appeared in some of the bilateral organizations and increasingly among NGOs (Dolan, 1999). Some samples include:

UNICEF currently supports a range of school health programs in water, sanitation, and hygiene; life skills/AIDS; child-to-child and extracurricular activities; and health and nutrition, including the provision of micronutrients, anthelmintics, and malaria tablets.

·The World Bank's investment has primarily been through educational projects, but also through health, nutrition, and social protection credits. The Bank has created a specific school health thematic group and has a specific school health initiative for Africa. An increased investment in school health is also expected through a partnership on this issue with PAHO for Latin American countries (Bundy, 2000).

The Canadian International Development Agency is a leading donor in nutrition programming. Since 1992, CIDA has contributed more than $87 million to nutrition projects and an additional $120 million to integrated projects that combine nutrition with health, basic education, and income generation activities.

CARE supports a range of school health and nutrition projects, including school health education in Kenya using Child-to-Child approaches; a school nutrition project with community-based activities in Laos; and a Children's Health and Environment magazine project in Thailand (Dolan, 1999).

For more detail about a broad range of school health and nutrition programs carried out and financed by donor agencies, refer to the "School Based Health and Nutrition Programs: Findings from a Survey of Donor and Agency Support, Carmel Dolan, 1999" (http://www.ceid.ox.ac.uk/schoolhealth/download%20documents.htm).
 
9. International conferences have addressed school health.
 
During the past decade, many major international conferences brought together important leaders and change agents and gained international attention. School health issues were addressed in various contexts as part of these conferences. Figure V gives an overview of selected conferences and the school health issues they addressed.
 
10. Various barriers still exist that can hinder progress toward effective and sustained school health and nutrition interventions.
 

Despite the encouraging global trends of the past decade, barriers, controversies, and missed opportunities continue to impede the implementation and effectiveness of school programs at the national and local level. Significant work is still needed to make the hope of a Health-Promoting and Child-Friendly School a reality for most schools. Country and regional representatives around the world reported the following national barriers:

The absence of political concern and national legislation to support school health programs.

The lack of a well-defined national strategy and policies for the promotion, support, coordination, and management of school health programs. · Limited funds allocated for school health programs or the inequitable distribution of existing resources.

Weak links between the health, education, and other relevant sectors.

The failure to escalate pilot projects to large programs.

The lack of data, particularly relevant disaggregated data, helpful to program planning.

Obstacles to effective partnerships for school health were identified by participants in the World Education Forum in Dakar, Senegal:

Different mind-sets and ways of thinking about conceptual frameworks

Cultural barriers

Competition for funding

Hostility toward partnerships

A lack of clear guidance in creating effective partnerships

Obstacles repeatedly identified at the local and school levels include: ·

A lack of awareness and support for school health programs.

An inability to sustain the quality and even the existence of school health programs.

The overcrowding of pupils in schools and of content in the curriculum.

A scarcity of trained people (including teachers) to implement school health programs.

The inadequate supply and production of teaching and learning materials and resources, including supplies, books, and equipment.

Limited or no funding to support health activities.

A lack of monitoring and evaluation of current school health programs.

The deterioration of the initial positive effects of many school health interventions due to unsupportive conditions in the school and its surrounding environment (e.g., the availability of drugs, tobacco, and alcohol; messages in the media that contradict messages promoted at school).

Finally, many schools still exemplify unhealthy living, where teachers and sometimes students smoke, where the only food choices are unhealthy, dirt is prevalent, and harassment is unchecked. There is an urgency and opportunity to use the knowledge, momentum, and international commitment gained since Jomtien to tackle the operational challenges that impede progress within both countries and schools.
 
To overcome these barriers, strong and genuine partnerships at all levels-i.e., between different sectors, between governmental and nongovernmental agencies, between teachers and health workers, between school and parents and the larger community-are critical to successful school programs. To make partnerships work, it is important to remember the common denominator that connects the various sectors, disciplines, and specialists: the larger social development agenda and the welfare of children.
 

The FRESH framework is a good example of how international agencies can work together. To achieve similar cooperation at national and local levels, the following WHO publications may provide useful guidance:

Improving School Health Programs: Barriers and Strategies. WHO/HPR/HEP/96.2

Local Action: Creating Health-Promoting Schools. (Both are available at: www.who.int/hpr/gshi/docs/index.html; or from WHO, Dept. of Health Promotion and NCD Prevention and Surveillance, 20 Avenue Appia, CH-1211 Genève 27, Switzerland.)

Regional Trends
 

Progress in school health and nutrition has varied dramatically across regions and nations. Figure IV shows major regional trends and accomplishments in school health and nutrition in Africa, the Americas, Europe, the Middle East, South and East Asia, and Australia during the past decade. This figure also lists barriers to school health experienced in these regions and activities planned for the future. For example:

In Central and Eastern Europe, many of the formal mechanisms that were in place in 1990 providing social services to young people, including those through the educational system, have deteriorated. This change occurred when the communist system fell apart and with it the numerous structures that were reaching out to young people.

In the Western Pacific, extensive accomplishments have taken place to create Health-Promoting Schools, supported by national policy frameworks and a regional technical assistance network. ·

Countries like Guinea and Indonesia have systematically developed comprehensive school health programs with incentives and awards for local schools, and countries in Africa, such as Uganda and Zimbabwe, have made excellent progress with skills-based health education.

During the past decade, we have seen the best thinking about education and health coalesce into several frameworks that identify the core principles shared by professionals and practitioners around the world. Definitive research results proliferated, and collaborative efforts expanded. Even failures and the tragedies of HIV infection have taught us profound lessons that can guide us in future efforts.
 
The access to and attainment of education and health must therefore drive all development policies, and many countries may need to rethink their social and economic priorities. Education for All should be seen as the foundation for access for each and every person to each and every level and form of education, and the quality of education should be seen, not only in terms of educational standards, but also of relevance. The direct links to health are clear: education has a fundamental role to play in personal and social development, and it is unlikely that the goals of education will be achieved without significant improvements in the health of both students and teachers.
 
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