Conclusions
The rationale for school-based health and nutrition programs and the approach to their implementation have undergone a paradigm shift over the past two decades.
The traditional perception of these programs as seeking to improve the health of schoolchildren cannot be justified on the basis of mortality or public health statistics alone. Instead, it is increasingly recognized that a major—perhaps the major—impact of ill health and malnutrition on this age group is that on cognitive development, learning, and educational achievement. In consequence, the clearest benefit of school health and nutrition programs is measurable in terms of education outcomes and their economic returns. The scale of benefit is significant: school health and nutrition interventions can add four to six points to IQ levels, 10 percent to participation in schooling, and one to two years of education. This scale of benefit can add 8 to 12 percent to labor returns and provide a rate of return that offers a strong argument for public sector investment.
Compelling evidence suggests that education qua education can help protect individuals from HIV infection. Achieving EFA goals and combining this outcome with school health programs that help establish lifelong positive behaviors are now recognized as essential to the multisectoral prevention response to HIV/AIDS.
The scale of the education benefit and the role of education in the fight against HIV/AIDS mean that school health and nutrition programs are today seen as a priority for both the education and the health sectors. This focus, in turn, has resulted in a shift toward public health rather than clinical intervention and toward school-based delivery rather than health system approaches. These policy changes enhance cost-effectiveness and social progressiveness, because delivery through the school system is an order of magnitude less costly than using health systems and in low-income countries is better targeted to the poor.
These changes in emphases have coincided with significant technical and political policy reform. Technical consensus around the FRESH framework has encouraged countries and agencies to develop programs around a common coordinating principle, while the political imperative has been strengthened by the recognition that school health and nutrition programs are essential to achieving EFA and the Millennium Development Goals and are at the center of the preventative response to the HIV/AIDS pandemic.
Although much of this change has evolved over the past two decades, significant acceleration has occurred since the World Education Forum in 2000. Today, a majority of low-income countries have recognized the need for school health and nutrition programs and are seeking to implement them.
Notes
1. These calculations assume the following: a return to an additional year of school is 7 percent; wage gains are earned over 40 years in the workforce, discounted at 5 percent per year with no wage growth; annual wage earnings are US$400 per year, which is below the estimated agricultural and nonagricultural annual wages for low-income countries (World Bank 2003). The opportunity costs of the additional schooling (child labor) have not been considered but are likely to be negligible.
2. These calculations assume that a pupil's falling behind the equivalent of one year in test scores has the same effect on earnings as losing one year of schooling; that the advantage that third graders have over second graders, for example, is the same as the advantage someone who has studied for a total of three years has over someone who has studied for two years; and that the impact of first-grade examination scores on the probability of transition from one class to the next is the same at each grade level.
3. If an increase of 1 SD in exam scores leads to children being 4.8 times as likely to reach seventh grade, the increased likelihood of reaching seventh grade because of a 0.25 SD increase can be calculated as EXP (0.25 x LN(4.8)).
