Evaluation of a comprehensive school health programme in Zambia

Lead Research Organisation: London School of Economics and Political Science
Department Name: Health Policy


Compared to children under 5, the needs of aged 5 to 14 years have been historically overlooked. Yet these children also face high levels of health-related challenges, caused or compounded by inadequate access to prevention and treatment, during a period critical for their development. 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 turn, lack of access of school-aged children to prevention and treatment has detrimental effects on a range of short- to long-term health, education, and economic outcomes. The World Health Organization recommends the implementation of comprehensive school health programmes (SHP), but these recommendations remain hardly implemented in low- and middle-income countries.

Since 2015, an NGO called Healthy Learners (HL) has partnered with the government of Zambia to develop such a comprehensive SHP centred on the concept of "School Health Workers": a few teachers in each school trained and equipped to provide health education, coordinate the delivery of preventative services with clinics, and make preliminary diagnoses thanks to a tablet-based clinical decision tool, allowing them to refer severe cases to clinics, where learners receive priority treatment.

This project aims to rigorously assess the impact of the SHP on a range of health and education outcomes and better understand the indirect effects of the program on teachers and clinics. We will rely on a cluster-randomised controlled trial, in six districts of the Copperbelt and Luapula provinces. 225 schools will be randomly selected and randomized to receive one of three interventions: (1) a comprehensive SHP (n=90 schools) corresponding to the full model developed by and implemented HL; (2) a limited range of school health activities (n=75) provided and implemented by the government, as per the current situation; (3) an enhanced range of health activities (n=60) where HL will support the government to ensure the reliable and regular provision of planned activities (mainly deworming and vitamin A).

The study will draw on a range of methods and data sources. Implementation, uptake and cost of the program will be assessed through administrative data from the program itself, and qualitative interviews with members of the school communities. To assess the causal impact of the program on health and education outcomes, we will select 60 learners in each school, and conduct surveys before and 12 and 24 months after the start of the SHP, with objective health outcomes measured at endline. We will use pictorial health diaries to collect detailed and reliable data on illness spells and health-seeking behaviours. We will explore potential indirect effects on teachers through three school surveys and on clinics capacity, through health facility assessments. Finally, we will test if the program can lead to improved human capital accumulation in the longer-term, through positive changes in educational aspirations, well-being and sexual and reproductive health outcomes.

The results of the study will contribute to the limited evidence base on school health programs in LMICs and will inform the scale-up of the SHP in Zambia and similar settings. The impact in Zambia will be facilitated by the strong links between the research team and the Ministry of Health and Ministry of Education, who have been involved in the planning of the project. Finally, the project will also have a strong capacity-building component, through the participation of several young researchers (most of whom will be from Zambia) supported and mentored by the senior members of the team, and the organisation of training workshops in Zambia aiming to strengthen evaluation skills of members of all partner organisations.

Technical Summary

Recognizing the understudied health challenges faced by children aged 5-14, this research evaluates a novel school health program (SHP) in Zambia, developed by an NGO in partnership with the Zambian government. The comprehensive SHP trains teachers to become "School Health Workers" who deliver health promotion talks and preventive services; and, via tablet-based diagnostic tools, assess, treat or refer sick learners to clinics.
We will undertake a cluster-randomised controlled trial in 225 schools, randomly allocated to the delivery of (i) usual school health activities, (ii) enhanced school health activities; or (iii) the novel SHP. We will also conduct a mixed-method process and economic evaluation.
The process evaluation will draw on several data sources, including program data from Healthy Learners, qualitative interviews with staff, parents and implementers; as well as surveys at midline and endline after 1 and 2 years of exposure. We will look at the effect of the intervention on the prevalence of anaemia, stunting and malaria, our primary outcomes evaluated at endline. We will measure impact on illness incidence and duration, and health-seeking behaviours, as well as learning and educational outcomes. Indirect program effects on teaching staff and clinic capacity will be explored via school surveys and health facility assessments. The study will also evaluate the program's potential for long-term human capital development by analysing changes in educational aspirations, well-being and pregnancy incidence.
The project will enhance the limited knowledge on SHPs in low- and middle-income countries, guiding SHP expansion in Zambia and analogous contexts. The active involvement of the Ministries of Health and Education ensures the project's local relevance and potential for impact. The project will also build capacity, by nurturing early-stage researchers, predominantly from the region, and fostering local evaluation skills through training workshops.


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