Children across India are back to school for in-person classes after an unnecessarily prolonged and arguably unwarranted closure (especially for the last one year) in the wake of the COVID-19 pandemic. It is time for concrete policy measures and actions that target schoolchildren. On the education front, while there has been some discourse on ‘learning recovery’, there is an urgent need to factor in the health needs of schoolchildren. One of the reasons school health services receive inadequate policy attention is because health-care needs are often equated with medical care needs. Though school-age children have a relatively low sickness rate (and thus limited medical care needs), they do have a wide range and age-specific health needs that are linked to unhealthy dietary habits, irregular sleep, lack of physical activity, mental, dental and eye problems, sexual behaviour, and the use of tobacco and other substances, addiction, etc. Then, the health knowledge acquired, and lifestyle adopted in the school-going age are known to stay in adulthood and lay the foundations of healthy behaviour for the rest of their life. For example, scientific evidence shows that tobacco cessation efforts are far more successful if started in school.
The evolution
The first documented record of school health services in India goes back to 1909 when the then presidency of Baroda began the medical examination of schoolchildren. Later, the Sir Joseph Bhore committee, in its 1946 report, observed that school health services in India were underdeveloped and practically non-existent. In 1953, the secondary education committee of the Government of India recommended comprehensive policy interventions dealing with school health and school feeding programmes. The result was programmatic interventions, led by a few selected States, that mostly focused on nutrition. However, school health has largely remained a token service.
In two and half years of the COVID-19 pandemic, there has barely been any serious initiative about school health. In the first week of March 2022, the government of Delhi began 20 school health clinics with the promise of more. Though small, this initiative has two messages. One, it recognises the importance of school health services in the post-pandemic period. Two, the importance of multi-stakeholder partnership for school health services as these are being set up through corporate social responsibility funding from a donor on the one hand and internal collaboration between health and education departments within government on the other. On a flip side, by the Delhi government’s own assertion, these clinics are curative focused services. They also highlight the main issue: what makes comprehensive school health services has still not been fully understood.
FRESH approach
One of the reasons for wrongly designed, and often very rudimentary, school health services — not only in India but also in most low- and middle-income countries — is, arguably, limited understanding and clarity on what constitutes well-functioning and effective school health services. This situation co-exists in spite of much evidence guided by international literature. UNESCO, UNICEF, the World Health Organization (WHO) and the World Bank have published an inter-agency framework called FRESH — an acronym for Focusing Resources on Effective School Health. The FRESH framework and tools propose four core areas and three supporting strategies. The core areas suggest that school health services need to focus on school health policies, i.e., water, sanitation and the environment; skills-based health education and school-based health and nutrition services. The supporting strategies include effective partnerships between the education and health sectors, community partnership and student participation.
Additionally, guidelines by the Centers for Disease Control and Prevention, Atlanta, U.S. advise that school health services should focus on four main areas of acute and emergency care; family engagement; chronic disease management; and care coordination. According to WHO , school health services should be designed based on local need assessment; should have components of health promotion, health education, screening leading to care and/or referral and support as appropriate. The objective of school health services has to be the promotion of positive health, prevention of disease, early diagnosis, treatment and follow up, raising health consciousness in children and enabling the provision of a healthy school environment.
In the last three decades, many countries ( especially in Europe), have successfully implemented these approaches as part of the health-promoting schools (HPS) initiative. Clearly, there is a lot to learn in terms of designing school health services.
Opportunity in reopening
As schools reopen to full capacity, there is a need and an opportunity for a proactive approach for having expanded and strengthened school health services.
First, every Indian State needs to review the status and then draw up a road map to revamp and strengthen school health services, along with a detailed timeline and dedicated budgetary allocation. The Fifteenth Finance Commission grant for the health sector should and could be leveraged.
Second, build upon the existing school health infrastructure; the renewed focus has to have comprehensive, preventive, promotive and curative services with a functioning referral linkage. Health talks and lifestyle sessions ( by schoolteachers and invited medical and health experts) should be a part of teaching just as physical activity sessions are. Some of the teaching must look at adolescent sexual health; also, subjects such as menstrual hygiene, etc. should be integrated into regular classroom teaching.
Third, school health clinics should be supplemented with online consultation for physical and mental health needs. This could be an important starting point to destigmatise mental health services.
Fourth, the role and the participation of parents, especially through parent-teacher meetings should be increased. Parents need to be sensitised about how school health services are delivered in other countries; this may work as an important accountability mechanism to strengthen school health. Innovative approaches that offer limited health services to parents, families and even schoolteachers could increase use, acceptance and demand.
Fifth, the Government’s school health services initiatives do not include private schools most of the time. Private schools do have some health services, which are nearly always restricted to curative care and taking care of emergencies. Clearly, school health services should be designed to take care of schoolchildren be they in private or government-run schools.
Sixth, under the Ayushman Bharat programme, a school health initiative was launched in early 2020, but its implementation is sub-optimal. There is a need to review this initiative, increase dedicated financial allocation to bring sufficient human resources and monitor performance based on concrete outcome indicators. Otherwise, it will end up being a ‘missed opportunity’.
Seventh, children are the future of society, but only if they are healthy and educated. Therefore, elected representatives, professional associations of public health and paediatricians shoulder the responsibility — every citizen should raise the issue and work towards improved school health services being present in every State of India.
A few weeks ago, following a review of the implementation of the National Education Policy, the Prime Minister’s Office (PMO) is said to have advised regular health check-ups and screening schoolchildren. Some letters were said to have been sent to the Health Department and requests made to depute medical interns and students in post-graduate courses to conduct a health check-up in schools. Such an approach on an issue that needs a thorough approach is akin to ‘tokenism’. India’s children need better handling than this.
For a platform
Every challenge has a silver lining The onus is on health policy makers and programme managers in every Indian State to do everything in the best interests of children. The Departments of Education and Health in every Indian State must work together to strengthen school health services. It is an opportunity to bring children, parents, teachers, health and education sector specialists and the Departments of Health and Education on a common platform to ensure better health and quality education for every child in India. A convergence of the National Health Policy, 2017 and National Education Policy, 2020 should result in the provision of comprehensive school health services in every Indian State.
Dr. Chandrakant Lahariya is a primary-care physician and public health specialist. He has done extensive work on school health services, including school reopening in India. E-mail: c.lahariya@gmail.com
