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[ Health ]

Fit for school

In the Philippines, schools are introducing simple and effective programmes to prevent common childhood diseases. This is a model case of policymaking.


[ By Bella Monse, Habib Benzian and Ralf Panse ]

Primary health care is essential to improve the living conditions of poor people, as the WHO’s Commission on Social Determinants of Health emphasised in a recent flagship report ­(CSDH, 2008). Launching the report, Margret Chan, the WHO’s director general, stressed the relevance of preventive action. Pointing to escalating health-care cost she said: “We simply cannot afford the way we go about doing health care nowadays without tackling and doing more prevention.”

Schools are a good starting point for preventive action. During the World Education Forum in Dakar in 2000, the WHO agreed with UNICEF, UNESCO and the World Bank to cooperate on promoting and implementing health programmes in schools. As a guideline, they launched the Focusing Resources on Effective School Health (FRESH) framework, which recommends focusing on interventions that can be implemented everywhere, even in resource-poor schools of low- and middle-income countries.

Education is the backbone of development in any given country; and in order to be really fit for school, children need to be healthy. Those who suffer poor health cannot concentrate or actively participate in school. Healthy children, on the other hand, attend school more regularly and can benefit fully from what the education system has to offer. School health programmes therefore have the potential to link resources for education, health, nutrition and sanitation at one venue: the school. The school system reaches a large share of the child population between six and 12 years of age.

In the Philippines, the FRESH approach was introduced through a programme called “Fit for School”. It promotes an essential health-care package and addresses the diseases most prevalent among children in the Philippines. Recent studies indicate that
– nearly all children suffer severe tooth decay,
– two thirds are infected with intestinal worms, and
– one third has a body mass index categorised as below normal.

In the past, these problems were socially accepted as normal and, accordingly, neglected by the Philippines health care system. Of course, they have a huge impact on the physical and mental development of children, their school attendance, their quality of life and their ability to resist other serious and potentially life threatening diseases. Worm infections for instance cause anaemia, reduced physical growth, delayed motor activity and poor mental development. In other words: malnourished children become even more malnourished. Children who suffer from toothache cannot eat, sleep or concentrate at school, and their growth and development are affected.

Poverty is a key determinant of people’s health. Whether at school or at home, overcrowded buildings, lack of clean water and sanitation facilities are the root causes of many diseases, and so is lack of healthy and appropriate food. Problematic environments keep children trapped in a cycle of poverty for a lifetime. The Fit for School programme accordingly intervenes in common routines through
– daily supervised handwashing with soap prior to recess,
– daily supervised toothbrushing with fluoride toothpaste, and
– bi-annual de-worming of all children.

The costs are comparably low. The­ ­necessary materials (toothbrushes, toothpaste, soap and de-worming drugs) are available at less than half a Euro per child and year. If properly implemented, the programme’s health benefits are tremendous. Selected evaluations of the programme have confirmed findings published in international literature:
– infectious diseases including diarrhoea and respiratory infections are reduced by 30 to 50 %,
– the progression of caries is reduced by 40 to 50 %,
– the prevalence of helminth infections sinks by 80 %,
– the number of children with below-normal height and weight is reduced by 20 %, and
– school attendance rises by 20 to 25 %.


Community action

The Fit for School Programme is implemented by adequately trained teachers and school administrators, rather than by health professionals or community workers. Of course, health programmes in schools also need the active involvement of parents. The entire community must assume responsibility for improving access to water and sanitary facilities in schools.

Schools are indeed good entry points for facilitating community action: Nearly all Filippino villages have elementary schools, and nearly all village people are in some way members of the school community, either as students, teachers, parents or relatives. Children spend most of their day at school, and they can become agents of change because they bring home knowledge that potentially affects family behaviour. The Fit for School programme thus creates opportunities to improve water and sanitation matters beyond the school proper.

As the health sector in the Philippines is decentralised, the funding of health care is a local matter. Municipal and provincial governments provide the budgets needed for Fit for School. Currently the programme is implemented by the Philippines’ Department of Education in close cooperation with 20 different units of local government. Some provinces are running the programme at a pilot level; others have already implemented it in all schools of the province.


History

The Fit for School programme developed from a five-year oral health programme in Misamis Oriental Province on the island of Mindanao. Initially, it was carried out by a German NGO in cooperation with the Department of Education. In 2003, school-based fluoride toothbrushing programmes were implemented in pilot schools in Cagayan de Oro, financed by the city government. Research on cost-effective interventions was supported by the WHO Collaborating Centres on Oral Health in Nijmegen, Netherlands, and Jena, Germany. On the basis of these initiatives, the more comprehensive “Basic Hygiene Programme”, which included daily hand washing in schools on top of brushing teeth, was designed.

In 2005 and 2006 the Department of Education undertook a national survey, investigating the oral health and nutritional status of elementary-school children. Subsequently, several strategic workshops emphasised the need for massive preventive-health measures in schools.

Last year, the Province of Misamis Oriental was the first to implement the Fit for School programme in all day-care centres and public elementary schools. Covering 110,000 children, it was entirely funded by the provincial health budget.

This year, 19 other provinces in the Philippines started to implement the Fit for School programme in pilot areas. GTZ supported the kick start of the project in some provinces by providing material for 100,000 children. There are plans to scale up the coverage all over these provinces. Currently half a million children have access to the programme. The total number of children enrolled in elementary schools in the country is 12 million and the goal is to cover at least 50 % of them in the next three years.

Assistance has been provided to the whole process over a period of four years. This included
– the national school-health survey,
– strategic planning,
– meetings with governors to agree on the allocation of funds,
– capacity building,
– facilitation of collaboration between the education and health sectors, and finally
– monitoring and evaluation.

InWEnt played a crucial role, and so did private-sector companies such as GlaxoSmithCline. CIM supported the programme by assignment of a health expert to the Philippines Department of Education.


Outlook

Primary education, reduction of child mortality and morbidity as well as increased access to safe water and sanitation are key components of achieving the UN Millenium Development Goals. Schools are appropriate places to reach out to children and their families to support preventive health care and, more generally, promote healthy lifestyles. Success, however, depends on cooperation between the health and the education sectors.

The Philippines’ Fit for School programme has recently gained increased international attention. The FDI World Dental Federation and private-sector partners are planning to start a public-private partnership with German Technical Cooperation (GTZ), a governmental aid agency. Based on the Fit-for-School experience, other countries will be supported in establishing similar preventive health programmes in schools.

D+C, 2008/11, InWEnt Forum, Page 434-435