Evaluation of a Comprehensive School Health Program in Rural Zambia

The school health programme, delivered by the Zambian Government in partnership with Healthy Learners (HL), seeks to make schools an entry point into the healthcare system by training and supporting teachers as community health workers, tasked to engage with local communities, promote health behaviours, and refer sick learners to health facilities. The main components of the programme are described in detail below.

1) School Health Workers:
In each school, teachers are selected to become school health workers (SHWs). Following a two-week training, SHWs perform two main roles:
1) they deliver health talks in all classes and coordinate the delivery of preventative care with local clinics (e.g. deworming campaigns);
2) they take turns to be on duty in the ‘school health room’, a purposefully constructed building where sick students can receive care and rest if needed.
With the help of a tablet-based clinical decision support system (CDSS) which does not follow a branching logic to minimize input errors and uses Bayesian logic to weigh reported symptoms (Finette, McLaughlin et al. 2019), SHWs follow a suggested course of action which builds upon recommended WHO guidelines. At the end of each screening, a SHW follows one of three courses of action:
- They provide reassurance that the symptoms are self-limiting and that no specific treatment is required beyond possible symptomatic relief medicines that they can dispense (e.g. paracetamol);
- They provide treatment for a limited number of conditions (malaria, diarrhoea, schistosomiasis, pneumonia, conjunctivitis),
- They refer the child to the public clinic associated to the school to be further assessed by a healthcare professional. The referral can be normal, in which case the guardian of the child is contacted and asked to take their child to the clinic, or urgent for severe conditions (in which case the SHW may accompany the child to the clinic themselves).
This system ensures efficient health-seeking behaviours by school-age children, limiting unnecessary visits to the clinic (overuse) and lack of or delays in required referral (underuse).

2) Priority referral system:
With the support from the Ministry of Health and engagement with the local clinics, children referred by SHWs are given priority by health care workers who see them within 30 minutes of arriving at the facility. This “fast-track” referral system is facilitated by the referral form containing information about symptoms and suggested diagnosis by the CDSS. The system ensures that parents do not have to waste precious time taking their children to facilities.

3) Monitoring of children’s illness.
A proactive system is set up to actively monitor the absenteeism of children due to illness. A ‘buddy system’ is introduced in each class, whereby children are allocated to a small group and encouraged to signal to SHWs when one of the members of their buddy group is absent due to illness. SHWs follow-up with parents of signalled children to discuss health-seeking options. After a sick child is referred to a facility, SHWs receive a feedback form filled by the clinic which help them follow up with the parents to discuss adherence to treatment and return to school.

4) Preventive programs:
SHWs coordinate with local health authorities and clinics to ensure the timely and smooth delivery of deworming drugs, which in theory should be provided routinely by health authorities.

2025-09-01

2027-07-30

1. Any healthcare utilisation
2. Healthcare utilisation conditional on need
3. Attendance rate

1. Any healthcare utilisation
The proportion of learners who sought formal care (any government health centre or hospital, or the school health room). Equals one if reported at least once during the health diary observation period.

2. Healthcare utilisation conditional on need
Conditional measure of healthcare use, restricted to the sample of children who have experienced at least one ‘serious’ illness episode, defined as one which requires medical attention according to WHO c-IMCI and IMAI guidelines. The outcome is the ratio of the number of illness episodes during which a child seeks medical care over the total number of serious illness episodes experienced by a child, for all children who have experienced at least one serious illness episode over the period.


3. Attendance rate
The proportion of children on the school register present on the day of the spot check, with the denominator defined by children confirmed by school staff as enrolled in the selected class on the visit day. This is a repeated cross-section of whoever is enrolled at the time of each visit.

Malaria prevalence (health-diary biomarker survey)
Moderate-to-severe anaemia (health-diary biomarker survey)
Illness burden and recovery (health diaries)

Malaria prevalence (health-diary biomarker survey): a binary indicator equal to 1 if the RDT is positive for P. falciparum, non-falciparum species, or a mixed infection.

Moderate-to-severe anaemia (health-diary biomarker survey): a binary indicator equal to 1 when measured hemoglobin (HemoCue, g/dL) falls below WHO thresholds. Haemoglobin is first adjusted for elevation using the WHO (2024) continuous adjustment, defined in g/L as 0.0056384 times elevation in metres plus 0.0000003 times elevation squared, evaluated at each school's recorded GPS elevation and subtracted from the measured value. Moderate-to-severe anaemia is considered when adjusted haemoglobin is below 11.0 g/dL, a threshold common to all age bands represented in our sample.

Illness burden and recovery (health diaries): We will construct two measures from the daily roster's symptom records. The first is the share of diary days on which the child reported any symptom, defined for every child in the diary sub-sample including those who are never ill, and so requiring no conditioning on illness status. The second is episode duration, the number of consecutive symptom days in an illness episode, estimated as a discrete-time hazard of symptom resolution so that episodes still ongoing at the end of the observation window contribute their observed days rather than being dropped; episodes beginning on day 1 are excluded as truncated, as elsewhere. We report both overall and separately for serious episodes. Because duration is defined only among children who fall ill, and illness is itself a potential programme outcome, we read the episode-level estimates as characterising the mechanism behind the child-level share rather than as a causal contrast in their own right.

Illness-related absence (health-diary): the diary's daily records flag whether the child attended school each day and record the reason for each absent day. The reasons are: illness (1), was menstruating (2), farming (3), school closure or school event (4), bad weather (5), religious reasons (6), market day (7), public holiday (8), fishing (9), mining (10), working with parents (11), no uniform/shoes/books (12), and other (-97). We treat a day as a health-related absence when the reason is illness (1) or menstruation (2). We restrict the sample to school days by dropping weekends and public holidays. Our measure is the share of the child's school days in the diary window lost to health-related absence: health-related absence days divided by total school days observed.

Randomisation: A school census identified 139 eligible schools in programme expansion regions. We randomly selected 120 from this list and these were randomised in June 2025 using a stratified procedure, with strata defined by district and by distance to the nearest health facility (above or below 1.5 km) and the school as the unit of randomisation.

Treatment arms: The trial has two arms - full school health programme (60 schools) and a pure control arm (60 schools), split evenly within every stratum. Intervention was delivered in Term 3 2025 (September-November)

Data collection activities: We collect data using two field instruments: the unannounced attendance spot checks (yielding register-based, cross-sectional attendance) and the health diaries and biomarker survey. Spot checks are repeated across terms 1, 2 and 3 in 2026, and terms 1 and 2 in 2027. Diaries are conducted in terms 1 and 2 2027, splitting the sample of schools randomly in half (preserving treatment allocation) which provides seasonal variation. Diaries follow a randomly selected sample of up to 24 learners per school, split evenly across gender and age groups, for 8 weeks with symptoms recorded daily; biomarkers are collected at the end of the diary periods so that any illness detected and treated does not affect the diary records. We do not collect a baseline survey.

Not available

Randomisation algorithm in STATA

School

Yes

120 schools

Up to 2,880 learners in the health diary sample (up to 24 per school), each observed daily over an 8-week window, giving approximately 161,280 learner-days of diary observation and up to 2,880 learners in the biomarker survey. Register-based attendance is a repeated cross-section of all children on the register in one randomly selected class per 3 or 4 grades each spot check, at each of five spot checks: approximately 2,100 class-level observations and 63,000 learner-level observations.

60 schools control, 60 schools with health programme