Audio: Levelling the playing field
HGSE Professor Matthew Jukes

In regions of the world where material resources are scarce, health and nutrition problems create major barriers for children's participation and success in school. In his recent book, School Health, Nutrition, And Education for All, HGSE Assistant Professor Matthew Jukes proposes a thought-provoking approach to improving education - by treating children's health problems. In this audio interview, Jukes explains why health interventions are useful for promoting education outcomes.

Q1. What is your rationale for this book on school health and nutrition programs?

"The rationale for this book is that school health and nutrition programs are becoming increasingly popular and being implemented in many countries around the world. And we wanted to bring together the evidence in one place that could help guide important policy decisions about these programs.

So many people don’t have difficulty in understanding why you would want to treat a child for intestinal worm infections. But this book is really about making the educational case for doing so. So, trying to understand what are the most effective interventions for improving children’s education, by first improving their health and nutrition.

But the book is also presenting evidence on the cost of these programs. In a world of competing resources, you have to make decisions about where you spend your money. We present the evidence for the cost-effectiveness of these programs. And we argue that school, health, and nutrition programs are one of the most cost effective ways of improving children’s education."

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Q2. What are your reasons for focusing on non-life threatening diseases? How many children are affected by these diseases, and how do they impact educational outcomes?

"So yes, when it comes to child health, many people’s focus is on life threatening diseases. And I guess it’s a question as to why the health programs that we look at are focusing on non-life threatening diseases.

Well, in fact, the great public health successes of the last generation have been about improving childhood survival, especially in the first five or so years of life. And now the question becomes what kind of life are these children surviving for? And many of the diseases that school-age children suffer are not life threatening, but have a serious impact on their education. So they’re less likely to enroll in school or attend school once they’ve enrolled. And they’re less likely to learn in class and more likely to drop out early if they’re suffering from diseases of poor health or nutrition.

So on the one hand, these diseases are not life threatening and they fall below many people’s radar. But on the other hand, they’re incredibly prevalent. The figures are staggering, that one third of the world’s children who are attending school are infected with worms. Half of them have anemia. Forty percent of them are at risk of malaria. And around one third are stunted in growth due to poor nutrition.

So we’re talking in the region of 200 million or 300 million school children in the world suffering from these diseases. So any impact that they have on children’s education is going to be multiplied hundreds of millions of times across the world."

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Q3. Are health programs really a good way to improve education? Wouldn’t focusing on other things, like teacher support or textbooks be a more direct approach?

"It’s an interesting question that if your interest is in improving children’s education, why focus on their health? And nobody’s expecting to be able to deliver education through a pill, but many do underestimate how important good health and nutrition is for children’s education.

I’ll just give you a couple of examples from our work. We did a study in the Gambia that found children who’d been protected from malaria in the first few years of life actually attended primary school for a whole year longer than their peers who had not been protected from malaria. So this simple health intervention can lead to children staying a whole year longer at school. And another recent project we did on malaria in Kenya found that by treating children for malaria, their concentration in classroom was considerably improved. In fact, we found an improvement in concentration equivalent to around a 15 point increase in IQ. So really a substantial improvement.

So good health and nutrition is not an incidental benefit for these children. It’s central to getting children into school and helping them learn whilst there.

Another great reason to focus on improving children’s health is that by doing so you always help the poorest children the most. This is for a couple of reasons. One is that the poor always suffer the greatest burden of disease, but also because even when rich and poor alike suffer similar levels of disease, treating these children always helps the education of the poorest to the greatest extent.

And such pro-poor interventions are actually few and far between. For example, if you give textbooks to schools, improve their supply of instructional materials, you often find that it’s the children who can already read and learn well by themselves, are the ones who benefit. So targeting inequality is actually quite difficult. But school health and nutrition programs offer a way to do it. So improved health and nutrition can bring substantial benefits to education, and it can also help target inequality.

But crucially, improving children’s health and nutrition can be relatively inexpensive and straightforward. All the diseases I’ve been talking about: worm infections, anemia, they can all be treated or prevented relatively simply. If you think, for example, about a vaccination program, children receive a life-long benefit from a vaccination that takes just a few minutes to administer. So although these programs are not without their logistical problems, you only need to get everything right for maybe one day in order for it to be successful.

So if you compare that with education, education is a different story. In order for children to complete a basic education, the conditions for learning have to be there, not just for a day or a week, but for every day of every school term for six, seven, or eight years. It’s a daunting task, but school health and nutrition programs are about bringing the simple effectiveness of health interventions to the field of education. They’re not the answer, but they’re the first part of the answer."

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Q4. In your book, you propose delivering medical treatments and nutrition initiatives through schools. What do you think are the major benefits of using schools in this way?

"Yes, using schools as the center for the treatment of disease seems like an unusual approach, but actually there are many good reasons for doing so. First off, there are huge cost savings in using the existing educational infrastructure to deliver these simple treatments. Where there are simple methods for giving treatments, and teachers can be trained in these methods, it actually turns out to be very, very cheap to treat children.

For example, it costs less than ten cents to treat a child for intestinal worm infections through a school-based health and nutrition program. Aside from the cost issue, the school delivery mechanism is also pro-poor, in that there are more schools than health clinics. And so the educational infrastructure has a greater reach than health services. This means that those living in rural areas, who are the ones who most need these services, are more likely to get them when they are delivered through the education system.

The benefits of using the educational infrastructure to deliver these treatments is easy to understand when you compare it to previous models for school health programs. One such model is the mobile health team. This is a team of health professionals who would travel around to communities and treat people for various diseases.

First of all, this method of delivering treatments is ten times more expensive than delivering treatments through schools. It also tends to favor those who are living in urban centers, which is where the teams are based."

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Q5. How have communities in the poorest regions responded to these initiatives? Is there any resistance to the programs?

"Yes, of course, it’s essential to get cooperation of communities in order to implement these programs. But in fact, many communities recognize the common health problems that are addressed by school health and nutrition programs. In fact, many parents and teachers that I talk to also understand the connection between health and education. So they can see that their children are not able to concentrate in class because of ill health and poor nutrition.

So this makes the introduction of school health programs much easier. They’re responding to demand that comes from the communities. But as with any such projects, especially those involving drug delivery, it’s important to get communities involved in the planning and implementation of projects, in order to guarantee support and sustainability of the projects."

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Q6. How would you assess overall progress in children's health and nutrition in the regions you discuss in your book? Have these programs moved communities significantly closer to achieving the UN's Millennium Development goal of universal primary education?

"It’s actually quite difficult to assess the progress being made in children’s health and nutrition in the regions we discuss in the book. Figures are released by UNICEF. And they show a marginal improvement in indicators like prevalence of anemia, and prevalence of stunting in Sub-Saharan Africa, or in South Asia.

But really there hasn’t been substantial progress compared to, for example, impressive increase in vaccination coverage in these regions. But these indicators inevitably take time to be collected. And I am actually greatly encouraged by the expansion of school health and nutrition programs around the world.

For example, there are now 25 countries in Sub-Sahara Africa that have school health and nutrition programs that have been introduced in the last few years. Also, if you look at the world of non-governmental organizations, the number of organizations that now have school health and nutrition programs as a central part of their education policies is really quite impressive.

So I am greatly optimistic for the future. And I hope that our book can provide a useful evidence base that can help the design of these programs, but also just help to make the case that improving children’s health and nutrition really is an important first step to achieving education for all."

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