Click here for search results

School Health

October 2003

Why a FRESH approach to School Health?
What can be done to improve school health and increase educational outcomes?
What can be done to improve health and educational outcome in school age children?
Evidence that School Health and Nutrition programs work and are cost effective
Where to start
Do’s and don’ts in community based school health programs
Key references
Key Links
PDF Versions (English, French, Portuguese, Russian)

 Logo - World Bank

Why a FRESH approach to School Health?

Ensuring that children are healthy and able to learn is an essential component of an effective education system. Good health increases enrollment and reduces absenteeism, and brings more of the poorest and most disadvantaged children to school, many of whom are girls. It is these children who are often the least healthy and most malnourished, and who have the most to gain educationally from improved health.

Effective school health programs that are developed as part of community partnerships provide one of the most cost-effective ways to reach school age children, adolescents and the broader community, and are a sustainable way to promote healthy practices including HIV/AIDS.

The new FRESH (PDF 166kb) framework (Focusing Resources on Effective School Health) is the starting point for developing an effective school health, hygiene and nutrition program in a more child friendly and health promoting school.

An effective school health, hygiene and nutrition program such as FRESH offers many benefits:

  • It responds to an increased need
    The success of child survival programs and the efforts of many governments and communities to expand basic education coverage have resulted both in a greater number of school-age children and in a greater proportion of these children attending school. Almost 90% of the world’s children survive beyond their fifth birthday and some 80% of these children are enrolled in school. In many countries, targeted education programs have ensured that many of these new entrants are girls for whom good health is especially important. Additionally, school aged children are the window of hope in the fight against HIV/AIDS. HIV/AIDS prevention is needed in schools.
  • It increases the efficacy of other investments in child development
    School health programs are the essential sequel and complement to early child care and development programs. Continuing good health at school age is essential if children are to sustain the advantages of a healthy early childhood and take full advantage of what may be their only opportunity for formal learning.
  • Ensures better educational outcomes
    Ensuring good health at school-age can boost school enrollment and attendance, reduce the need for repetition, and increase educational attainment. Good health practices can promote reproductive health and help avoid HIV/AIDS. It is estimated that the burden of disease for school-aged children 5-14 years is 11% of the total global burden of disease.
  • It improves social equity
    As a result of universal basic education strategies, some of the most disadvantaged children – girls, poor rural children, children with disabilities – have access to school for the first time. But their ability to attend school and to learn whilst there is compromised by poor health. These are the children who will benefit most from health interventions, since they are likely to show the greatest improvements in attendance and learning achievement.
  • It is a highly cost effective strategy
    School health programs help link resources for health, education, nutrition, and sanitation to an infrastructure – the school – that is already in place, is pervasive and is sustained. While the school system is rarely universal, coverage is often superior to health systems. And the school system has an extensive skilled workforce that already works closely with the community.


What can be done to improve school health and educational outcomes?

The FRESH framework: all schools, for all children.

What can be done to improve health and educational outcome in school age children?

The FRESH framework for School Health interventions includes health-related school policies, provision of water and sanitation, skills-based health education and health and nutrition services in schools.

Core Interventions

Target Groups

Health-related school policies
Increase the number of schools with adequate water and sanitation facilitiesClear policies to ensure the provision of water and sanitation in all schools The school population
  • % of schools with safe water and adequate sanitation facilities
Increase access to sanitation facilities for teachers, boys and girlsPolicies on basic hygiene education in curriculum that lead to increased demand and responsiveness from children, PTA and the community for well maintained facilitiesThe school population

The community

Adolescent girls
  • % of schools with well maintained sanitation facilities
  • Increased gross enrollment rates of girls, when adequate toilets are available in schools
Increase family life education and access to family planning servicesClear policy to include family life education and family planning in secondary school curriculum Adolescents
  • % of schools with family life education and contraceptive/STD counseling
Reduce drop-outs because of pregnancyClear policy that pregnant girls can stay in school and continue in school after delivery
Focus on women’s rights to education
Adolescent girls
  • Increased gross enrollment rates of girls
  • Reduced drop out of adolescent girls
Reduce tobacco and substance usePolicies that prohibit smoking and substance use in schools The school population
  • % of schools tobacco free
Reduce discrimination against people with HIV/AIDS and their familiesPolicies to avoid discrimination against people with HIV/AIDS and their familiesThe school population
  • Reduced number of children with HIV/AIDS and HIV/AIDS orphans excluded from schools
Provision of safe water and adequate sanitation in schools
Increase the number of schools with adequate water and sanitation facilities, well maintained and with separate facilities for boys and girlsSchool construction norms that include adequate water and sanitation, with separate facilities for boys and girlsThe school population especially adolescent girls
  • % of schools with safe water and adequate, well maintained sanitation facilities
  • Increased gross enrollment rates of girls
Reduce incidence of diarrhea and intestinal infections among school childrenSafe water available in schoolsThe school population and the community
  • Reduced absenteeism and repetition rates
Skills-based health education
Reduce the number of unwanted pregnancies and drop-outs from schoolSkills-based health education including family life education Adolescents
  • Increased gross enrollment rates of girls
  • Reduced number of girls who drop out due to pregnancy and discrimination
Reduce risk behaviorsand address lack of knowledge on HIV/AIDSSkills-based health education and HIV/AIDS/STD prevention included in school curriculumAll school children
  • % of school children with life skills to prevent HIV/AIDS/STD transmission
Reduce short term hunger and improve nutritionSkills-based nutrition educationAll school children
  • % of children that have food before they go to school
Reduce tobacco and substance abuseSkills-based health educationAll school children
  • % of school children who have used any tobacco product in the previous 30 days
School-based health and nutrition services
Reduce worm infectionsRegular dewormingAll school children
  • Reduce repetition rates, and drop-outs
Reduce micronutrient deficiencies and anemiaOral supplement of iron and vitamin AAll school children
  • Reduce repetition rates, and drop-outs


Evidence that School Health and Nutrition programs work and are cost effective:

  • Helminth infections are most commonly seen in school age children and cause iron deficiency anemia (IDA). IDA in children is strongly associated with decreased physical and mental development and impaired immune function. An estimated 210 million school age children suffer from IDA. Multiple studies have shown the benefits of treatment of IDA in pre-school and school age children through iron supplementation and regular deworming. Benefits include lower absenteeism, and higher scores on tests of cognition or school achievement. The cost is around US$1 per child each year.

School Health - Absenteeism

  • Provision of adequate water and sanitation facilities in schools in Bangladesh increased girls’ attendance by 15%. Interaction with family and demand for sanitation facilities at home was seen in 80% of children who acquired these practices at school.
  • A recent review of 144 different interventions demonstrated the impact on morbidity of general water, sanitation and hygienic interventions:
    • 36% median reduction of diarrhea from the safe disposal of feces
    • 35% median reduction of diarrhea from hand-washing with soap after contact with stools
    • 20% median reduction in diarrhea from protection of water from fecal contamination
    • 26% median reduction in diarrhea from the integration of hygiene education or promotion in water projects (Esrey and et al., 1990)
  • A 1997 UNAIDS review of 53 studies which assessed the effectiveness of programs to prevent HIV infection and related health problems among young people concluded that school-based sex education programs are an effective way to reduce risk behaviors associated with HIV/AIDS/STDs among children and adolescents.
  • In Jamaica, a program, begun in 1977, to motivate young mothers to choose education instead of continuing motherhood, helped 22,000 young mothers to return to school. The Ministry of Education changed the education code to allow teenage mothers in school. Adolescent pregnancies declined from 31% to 23% between 1977 and 1997. All of the children of the mothers in the intervention group are in school, and no pregnancies have occurred among the adolescent children of these mothers.
  • A WHO review of studies on sexuality education found that access to counseling and contraceptive services did not encourage earlier or increased sexual activity. In Europe and Canada where comprehensive sexuality education and confidential access to condoms are more common, the rates of adolescent sexual intercourse are no higher than in the United States and teen-age pregnancy is lower.
  • A CDC study found that each $1 invested in school-based tobacco prevention, drug and alcohol education and family life education saved $14 in avoided health costs.


Where to start

The FRESH framework was developed by a partnership of UNESCO, UNICEF, WHO and the World Bank, and launched at the World Education Forum, April 2000. The framework is the starting point for developing an effective school health hygiene and nutrition program in a more child friendly and health promoting school. The aim is to focus on interventions that are feasible to implement even in the most resource-poor schools. The core framework has four components that should be made available in all schools:

  1. Health-related school policies that, for example, do not exclude pregnant girls, that encourage healthy tobacco-free lifestyles, and that help maintain the education system in the face of HIV/AIDS.
  2. Provision of safe water and sanitation to provide a healthy learning environment that reinforces hygienic behaviors and provides privacy to promote participation of adolescent girls in education.
  3. Skills-based approach to health, hygiene, and nutrition education that focuses upon the development of knowledge, attitudes, values, and life skills needed to establish lifelong healthy practices and to reduce the vulnerability of youth and teachers to HIV/AIDS.
  4. School-based health and nutrition services that are simple, safe and familiar, and address problems that are prevalent and recognized as important within the community, including the provision of counseling to cope with the HIV/AIDS epidemic.

Implementation requires:
a) intersectoral partnerships, especially between health and education
b) partnerships with the community, especially PTAs
c) active involvement of the school children.


Do’s and don’ts in community based school health programs

  • Do make sure that the health and education sectors cooperate, and that agreements are written down in a “protocol d'accord”.
  • Do make sure that school health activities are accepted and supported by parents, PTA and students.
  • Do design a program that reaches the poorest children in the most isolated communities.
  • Do use a communication strategy that ensures that health policies are transparent and well understood by teachers, parents and students.
  • Do make sure that the community wants, and is able to maintain latrines, before they are built.
  • Do make sure that health education is based on real understanding of what should be done and not just academic knowledge.
  • Do monitor and evaluate all activities implemented.
  • Don’t overload the teachers – their first job is to teach.


Key references:

  • The Partnership for Child Development: Better health, nutrition and education for the school-age child.Transactions of the Royal Society of Tropical Medicine and Hygiene. 1997, 91:1-2.
  • WHO Information series on School Health (see WHO website click on "WHO Information Series on School Health")
  • FRESH, Focusing Resources on Effective School Health, World Bank, 2001 (see WB/PCD website)
  • Carolyn Winter et al, HDN 1999. Girls’ Education World Bank Support through IDA
    This 12 page paper on the rationale for girl’s education address the current and regional patterns in girl’s education lending
  • Mary Eming Young,1996Early Child development: Investing in the future.Directions in Development, World Bank. Page 7-12 describes the socio economic returns of ECD.
  • Judith Senderowitz, 2000. A review of program approaches to Adolescent Reproductive Health, Poptech assignment Number 2000.176, On page 16-19, in the chapter 4.2, Improving Knowledge, Skills, Attitudes, Self-efficacy describes school based sex/HIV education and evaluation of different approaches in this area.
  • M.J.Kelly, 2000. Planning for education in the context of HIV/AIDS. UNESCO: International Institute for Educational Planning.  This booklet stresses the need for the education system to react quickly and to envisage new, creative solutions. Education has a vital role to play in combating the epidemic, both in coping with the crisis but also because the “window of hope”, or least affected segment of the population , consist of school aged children
  • Joy Miller Del Rosso, Tonia Marek, 1996. Class Action, Improving School Performance in the Developing World through Better Health and Nutrition, World Bank.  This book is part of the series Directions in Development and summarizes how better nutrition and health for youths will enhance school enrollment, attendance and performance and also economic productivity and the health of future generations. 46 pages.
  • Monitoring helminth control programmes. Guidelines for monitoring the impact of control programmes aimed at reducing morbidity caused by soil-transmitted helminthes and schistosomes, with particular reference to school-age children. A guide for Managers of Control Programmes (II) WHO 99.
  • Nokes, C et al 1998 The effects of iron deficiency and anemia on mental and motor performance, educational achievement, and behavior in children: a technical review.
    This technical review summarizes the evidence and main issues regarding the relationship between iron deficiency anaemia and mental function in infants, pre-school and school-age children.
  • Mwanri L, Worsley A, Ryan P and Masika J (2000). Supplemental vitamin A improves anaemia and growth in anaemic school children in Tanzania, American Society for Nutritional Sciences
  • Sergio Meresman, 1999. The Ten Who go to School: School Health and Nutrition Programming in Latin America and the Caribbean. The World Bank, PAHO.
    The document provides an overview of the education and health status of the school- age child in LAC, and explores some of the options for future action.


Key Links

For further information, please contact Don Bundy, Principal School Health Specialist (

 PDF Versions


Permanent URL for this page: