Abstract
While much attention has been dedicated to the health and well-being of children under 5, the needs of older children have been historically overlooked. However, children between 5- and 14-years face health-related challenges higher than previously realized, during a period of life critical for physical, psychological, cognitive and social development. In Zambia, the context for this study, the prevalence of malaria is highest in children aged 5-17, with 40% of children testing positive in endemic areas; a study based in Lusaka, the capital also reported high levels of morbidity in primary school children, with 35% reporting febrile symptoms in the past two weeks, 66% reporting cough, 25% reporting diarrhea, and 32% having worms in their stool. Many of these problems are caused or compounded by inadequate access to prevention and treatment for school-age children. For example, they are less likely to sleep under a bednet than younger children. When ill, school-age children are less likely than other age groups to seek treatment, and when they do, less likely to seek care from formal providers. In Zambia, delayed treatment is often due to the high opportunity costs associated with long waiting times in over-crowded facilities, where children over 5 are no longer prioritized over adults. Long waiting times to access care are particularly acute when government health services are free, as in Zambia. In turn, health-related issues have a negative impact on education outcomes. They are a major cause of the 20-25% absenteeism rate observed amongst school children in Zambia, have been shown to lead to lower cognitive abilities, which, together with absenteeism, increases the likelihood of dropout and early marriage for girls.
In this study, we evaluate a programme which leverages the susbtantial expansion of primary school enrollment in Zambia and uses schools as a platform to improve access to preventive and curative healthcare services for children above five. Since 2015, our partner NGO Healthy Learners has partnered with the Zambian Government to develop a comprehensive and scalable school health program (SHP), making schools an entry point into the healthcare system. The SHP model consists of 4 key features: 1) building capacity by training teachers to become community health workers and building and equipping a school health room; 2) diagnosing and treating sick learners in school health rooms with the help of the ThinkMD clinical decision support system, or referring learners to the local health centre with a fast-track form; 3) proactive monitoring of absent and sick learners (e.g., following up after health centre referrals, a "buddy" system to check up on absent learners); 4) prevention through school health education (delivered by trained teachers) and supply of preventive care in partnership with local health facilities (e.g., vitamin A, deworming, etc.)
While many SHPs in low-income settings only focus on the delivery of some preventive services (eg. deworming, school meals, health talks), the comprehensive model creates a platform that improves access to and delivery of both preventive and curative services. Unlike a school nurse program, which is financially unsustainable, impractical in settings with health staff shortages, and places the onus of providing health services on one individual health worker, this model is integrated into the structures of the Ministry of Education and leverages resources from the entire school community to become involved in supporting the health of students.
We evaluate the impact of the SHP in a cluster-randomised controlled trial conducted in 225 schools, which we will randomly assign to one of three treatment groups: 1) a standard of care control group; 2) the School Health Programme; 3) only the mass drug administration (e.g. deworming) component of the SHP, which will enable us to benchmark the cost-effectiveness of the SHP against mass administration of deworming drugs. The proposed research will answer five main questions:
(1) What factors affect the implementation of the comprehensive SHP and how costly is it?
(2) What is the impact of the programme on health, health-seeking and education outcomes?
(3) What is the added value of such a comprehensive SHP, compared to (i) reliable (ii) or imperfect delivery of a limited range of default school health activities (e.g. deworming)?
(4) What are the indirect effects of the SHP on teachers, schools, health-workers and clinics?
(5) What are the potential implications of the programme for long-term human capital accumulation?