Research and Development Agenda
Reliable evidence suggests that ill health and malnutrition affect education access, participation, completion, and achievement, and that school-based health and nutrition programs can provide a cost-effective and low-cost solution. This evidence does not imply, however, that no uncertainties exist.
Cost-Effectiveness of School-based HIV/AIDS Prevention
Substantial evidence suggests that skills-based health education, including life-skills development programs, can promote positive behaviors and reduce the risks of exposure to HIV infection, and that girls' education programs have similar effects (Kirby 2002). Evidence also exists for a positive effect of completing education on HIV prevalence (de Walque 2004; World Bank 2002). What is lacking is direct evidence about the contribution that school-based prevention programs can make in reducing the incidence of HIV infection, as well as evidence for the relative cost-effectiveness of such programs compared with existing efforts to promote education completion and girls' education.
Cost-Effectiveness of Malaria Programs
Malaria occurs commonly in schoolchildren, particularly in areas of unstable transmission in Africa and Asia. It is a leading source of mortality in this age group and adversely affects education by reducing school attendance, cognition, learning, and school performance. Current school-based approaches focus on knowledge of the disease and the use of impregnated bed-nets but do not address the need for treatment of affected children. Yet presumptive treatment by teachers has been shown to significantly reduce mortality (Pasha and others 2003), and intermittent preventive treatment also shows considerable promise (Brooker and others 2000). There is a need to confirm the success of school-based treatment in different epidemiological settings and to address questions about the cost and sustainability of this approach.
Cost-Effectiveness of Targeting Food Aid
The high prevalence of malnutrition in children continues to be a major challenge for low-income countries. Providing food to children at school is often seen as an important part of the solution and is a major focus for food aid. However, the nutrition literature suggests that ensuring good nutrition earlier in life—certainly before 3 years of age, but perhaps earlier—is essential to ensuring an appropriate development trajectory throughout life (see chapter 27). Where food is limiting, it raises the question whether the first target should be preschool rather than school-age children. This debate has been blurred by admixing the nutrition outcomes with broader social and education issues. Clearly, providing a meal at school is socially desirable and can offer education benefits for children who otherwise would have to walk often long distances home to eat or remain hungry. It is also clear that schools represent an extensive and established network for providing nutrition interventions to very large numbers of children at a low cost per child. No comparable network exists to reach preschool children. However, from a nutritional perspective, it remains unclear whether ensuring good nutrition early in life has more effect on subsequent development—including educational achievement—than providing food at school age.
