UGANDAۣSCHOOLHEALTH   REPORT|2014 SABERCOUNTRY  Uganda   SABER Country Report SCHOOL HEALTH  2014        Policy Goals Status 1. Health-Related School Policies  School health is not included in the poverty reduction strategic plan (PRSP), and there is no published national policy on school health. There is no multisectoral steering committee coordination effort, although there is a multisectoral school health task force comprised of personnel from the Ministries of Education and Sports, Health, Local Government, Water and Environment,andGender,LabourandSocialDevelopment.Asituationanalysis was conducted to assess the need for inclusion of various thematic areas. There is a draft of the School Health Policy that includes a monitoring and evaluation(M&E)planforschoolhealthprogramming. 2. Safe, Supportive School Environments  Nationalstandardsestablishedtheprovisionforwaterandsanitationfacilities. However,nationalstandardsonhowtoaddressviolenceinschoolsarelacking. 3. School-Based Health and Nutrition Services Asituationanalysishasbeenundertaken,butnotallinterventionshavebeen scaledup.ThesituationanalysisassessedtheneedforschoolͲbasedscreening andreferraltoremedialservices,andtheseserviceshavebeenoutlinedinthe  draftnationalpolicy. 4. Skills-Based Health Education  The national school curriculum for primary school covers some but not all of theissuesidentifiedinthesituationanalysis.Teachersreceivetrainingtoteach the curriculumandthe materialisincludedinschoolexaminations.However, therearenoteachingmaterialsforlifeskills.  1 SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   Introduction EducationandHealthinUganda This report presents an assessment of school health Uganda has significantly expanded access to education policies and institutions that affect young children in since the implementation of the Universal Primary Uganda. The analysis is based on a World Bank tool Education (UPE) reform in 1997. The gross primary developed as part of the Systems Approach for Better enrolment ratio dramatically increased from 70 percent Education Results (SABER) initiative that aims to in 1996 to 117 percent in 1997. 8 By 2011, primary systematically assess education systems against enrolment was estimated at 8.1 million children (50 evidenceͲbased global standards and good practice to percentgirls),resultinginagrossenrolmentratioof110 help countries reform their education systems to help percent,thelowestithadbeensincethepassageofthe ensurelearningforall. UPE reform in 1997. 9 Following a similar trend, the  expectedprimarycompletionratehasbeendeclining.In School health policies are a critical component of an 2011, the expected primary completion rate was 35 effective education system, given that children's health percent, which was lower than the previous year’s rate impacts their school attendance, ability to learn, and of48percent.10Ingeneral,completionandachievement overall development. SABERͲSchool Health collects, ratesarelow.Over50percentofprimarypupilsingrades analyzes, and disseminates comprehensive information 3and6performedbelowthedesiredminimumaverage on school health policies around the world. The overall (50percent)fornumeracyandliteracy. objective of the initiative is to help countries design effective policies to improve their education systems, Student absenteeism in Uganda is high. One in three facilitate comparative policy analysis, identify key areas children in primary school does not attend school every to focus investment, and assist in disseminating good day (Figures 1 and 2). In island and fishing community practice. districts (Apac,Kalangala),anddistricts withagricultural  estateͲ or plantationͲbased livelihoods (Mityana, CountryOverview Kyenjojo), absenteeism may be higher than one out of Uganda is a lowͲincome country in SubͲSaharan Africa everytwochildren.Lowattendanceaffectslearningand withapopulationof37.6millionpeopleandapopulation hinders effective use of educational inputs. Teacher growthrateof3.3percentin2013.1GDPpercapitainthe absenteeismisestimatedat27percent.Otherproblems, country has been rising since 2000 when it was $883 to some identified by the head teachers, include: poor $1,365 in 2013 (constant 2011 international dollar) due textbook utilization by both teachers and learners, their to macroeconomic and political stability. 2 Despite limited availability notwithstanding; high number of positive economic growth and rising GDP per capita, school dropͲouts as reflected in the low completion povertyiswidespreadandparticularlyprevalentinrural rates; and low learner attendance. Irregular student areas. 3 The poverty gap at $2 a day (PPP) was 27.4 attendancehasbeenpartlyattributedto:lackofmidͲday percentin2009,whichislowerthanitwasin2006(36.4 meals at school; low teacher attendance; low societal percent).4Uganda’s human development index in 2013 appreciation of the longͲterm benefits of schooling and ranked it number 161 out of 187 countries, placing it in hence low learner support, as manifested in the lack of the low human development category. 5 Despite the basic scholastic materials (books and pens/pencils); and improvementinlifeexpectancyfrom48yearsin2000to lateenrolmentforschool(Figure2). 59 years in 20126, the prevalence of undernourishment hasincreasedfrom27percentofthepopulationin2000 to30percentin2012.7  1 6 WorldBank.2014a. WorldBank.2014a. 2 7 Ibid. Ibid. 3 8 U.S.GlobalHealthPrograms,2011. WorldBank.2014b. 4 9 WorldBank.2014a. Ibid. 5 UNDP,2013. 10 Ibid.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 2 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   Figure1:LearnerAbsenteeismbyGrade,UNPS2009/10 reinforcing school infrastructure developments to supporttheexpansion. AsashareofGDP,publicexpenditureoneducation was 3.3percentin2012.13In2012,expenditureoneducation was 14 percent of total government expenditure. 14 Expenditure on primary education as a percentage of government spending on education was 54 percent while secondary education received 25 percent in 2012.15 Health Uganda faces several health challenges. In 2012, approximately 60 percent of deaths were caused by  communicable diseases in addition to maternal, Source: Data from the Uganda Bureau of Statistics and computed by authors in “Improving Learning in Uganda Vol. 1: CommunityͲLed School Feeding prenatal, and nutrition conditions while 27 percent of Practices”in2013.11 deaths were caused by nonͲcommunicable diseases. 16  Prevalent communicable diseases in Uganda include Figure2:MostSeriousProblemsFacedbySchoolsas IdentifiedbyHeadTeachers,UNPS2009/10 HIV/AIDS, tuberculosis, malaria, and neglected tropical diseases (NTDs). 17 For example, approximately 7.2 percent of individuals between the ages of 15 and 49 were infected with HIV in 2012.18Health problems are exacerbated by inadequate access to clean water and sanitationfacilities.Approximately34percentofpeople in Uganda use improved sanitation facilities with no major differences between urban and rural areas.19The difference in living conditions for rural and urban residentsbecomesapparentwhencomparingthesetwo populations’ access to an improved water source. Roughly 95 percent of the urban population had access Source: Data from the Uganda Bureau of Statistics and computed by authors to an improved water source in 2012 when only 75 in “Improving Learning in Uganda Vol. 1: CommunityͲLed School Feeding percentoftheruralpopulationhadaccess.20 Practices”in2013.12  Thegovernmentisthusfacedwiththedualchallengeof Maternalandchildhealthconditionsaccountforalarge maintaining high enrolment levels and ensuring quality proportion of Uganda’s health burden although service delivery in order to reach both national morbidityandmortalityratesforthesegroupshavebeen development goals and the Millennium Development declining. 21 The fertility rate has decreased over time Goals on education. Government and development fromanaverageof6.9childrenperwomanin2000to6 partners’effortsarecurrentlyfocused onimprovingthe children per woman in 2012.22The infant mortality rate provision of key inputs for quality teaching and learning significantly decreased from 89 percent in 2000 to 45 processes, especially with regard to qualified teachers, percent in 2012. 23 Deaths were caused by pneumonia, instructional materials, and curriculum reforms, and asphyxia, prematurity, congenital abnormalities, and other health conditions. 24 In addition, malnutrition  11 18 Najjumba,I.M.,Bunjo,C.L.,Kyaddondo,D.,andC.Misinde,2013. WorldBank.2014a. 12 Ibid. 19 Ibid. 13 20 UNESCO,2014. Ibid. 14 WorldBank,2014b. 21 UBOS.2002.UDHS.Kampala:UBOS 15 22 Ibid. WorldBank.2014a. 16 23 WorldBank,2014a. Ibid. 17 24 GovernmentofUganda,2010. GovernmentofUganda,2010.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 3 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   decreasedfrom45percentin2000to34percentin2012 attendance and reducing dropout rates; and enhance among children five years old and younger. There has theircognitiveskillsandeducationalachievements. also been increased access to deworming and micronutrient supplementation programs. 25 The FourKeyPolicyGoalstoPromoteSchoolHealth prevalenceofwastingamongchildrenunderfiveyearsof age was 4.8 percent in 2011 while the prevalence of Therearefourcorepolicygoalsthatformthebasisofan anemia among children in the same age group was 56 effective school health program. They are interrelated percent in 2011, both lower than the previous years’ and impact the educational opportunities and rates.26 accomplishments of children. Figure 3 illustrates these  policy goals as well as outlines respective policy levers Physical and psychological abuse remains an issue in thatfallundereachofthesegoals. Uganda.In particular,sexualandgenderͲbasedviolence is common. 27 Limited funding and transportation The first goal is establishing healthͲrelated school resources reduce health workers’ capacity to address policies.Thisisanintegralpartofdevelopinganeffective sexualandgenderͲbasedviolence.28 school health program because it provides an opportunity for national leadership to demonstrate a commitment to school health programming and also TheCaseforSchoolHealth ensures accountability for the quality of the programs. An effective national school health policy can help a Thelinkbetweenhealthandacademicachievementhas governmentdevelopitsstrategicvisionforschoolhealth long been recognized in the developed world. In the and encourage program ownership. The policy should 1980s, however, there was a change in the approach to also have a multisectoral approach to encourage school health programs as more of them became proͲ cooperation because school health is relevant to many poor and focused on education outcomes. LowͲincome sectors,includingeducationandhealth. countries shifted their focus from a medicalͲbased approach that favored elite schools in urban centers The second goal is ensuring safe, supportive school toward schoolͲbased programs that sought to improve environments. This includes access to adequate water accesstoeducationandschoolcompletionbyimproving andsanitationfacilities,aswellasahealthypsychosocial health and tackling hunger. For example, deworming29, environment. Safe water and sanitation practices feeding 30 , malaria prevention 31 , and iron deficiency contribute not only to obvious health benefits but also prevention 32 interventions can improve school help boost girls’ attendance rates. 33 A school attendance and learning. These schoolͲbased administration that strives for a positive psychosocial interventions have proven to be most educationally environment by addressing issues such as bullying, beneficial to the children who are worst off—the poor, violence, and other stigmas has also shown to be thesick,andthemalnourished. consistentlyrelatedtostudentprogress. The SABERͲSchool Health and School Feeding initiative The third goal is delivering schoolͲbased health and provides evidenceͲbased tools to improve health and nutritionservices.Diseasesthatnegativelyaffectschool nutrition and avoid hunger, contributing to the greater children’sabilitytolearn,suchasthosecausedbyworm WorldBankeducationstrategythatidentifiesthreemain infections, are highly prevalent worldwide, especially goals for children: ensure that they are ready to learn among the poor. 34 These diseases, many of which are and enroll on time; keep them in school by enhancing preventableandtreatable,impactchildren’sattendance rates,cognitiveabilities,andphysicaldevelopment.This  25 31 Ibid. Fernandoetal.,2006;Clarkeetal.,2008 26 32 WorldBank.2014a. Pollittetal.,1989;SeshadriandGopaldas,1989;Soemantri,Pollitt,andKim, 27 Ibid. 1985 28 33 GovernmentofUganda,2010. Hoffmannetal.,2002. 29 34 Miguel and Kremer, 2004; Simeon et al., 1995; Grigorenko et al., 2006; Jukesetal.,2008. Nokesetal.,1992  30 vanStuijvenbergetal.,1999;Powelletal.,1998;Whaleyetal.,2003  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 4 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   makes screening for health problems imperative, along Each policy goal and lever of school feeding is with the treatment of parasitic infections, weekly methodically benchmarked through two SABER analysis supplementation to control iron deficiency anemia, and tools. The first is a scoring rubric that quantifies the othersimplebuteffectivetreatments.Interventionscan responses to selected questions from the SABERͲSchool alsoincludepsychosocialcounselingandschoolfeeding. Health questionnaire by assigning point values to the Health and nutrition interventions delivered through answers. The second tool is the SABERͲSchool Health schools systems can be highly costͲeffective because Frameworkrubricthatanalyzestheresponses,especially schoolshavetheinfrastructuretoserveasaplatformto the written answers, based on the framework’s five deliver simple health treatments and provide screening policygoalsandlevers.Formoreinformation,pleasevisit andreferralservices. the World Bank’s website on SABERͲSchool Health and School Feeding and click on the “What Matters” The fourth and final policy goal is skillsͲbased health FrameworkPaperunderMethodology. education. This skillsͲbased approach focuses on the development of knowledge, attitudes, and values that impact the longͲterm behavior and choices of school children. A skillsͲbased health education is essential to mitigatingsocialandpeerpressures,addressingcultural norms, and discouraging abusive relationships. Psychosocial,interpersonal,andlifeskillscanstrengthen students’ abilities to protect themselves from health threats and adopt positive health behaviors. A skillsͲ based health education program can include curriculum development, life skills training, and learning materials onsubjectssuchasHIV. UseofEvidenceͲBasedTools TheprimaryfocusoftheSABERͲSchoolHealthexerciseis gathering systematic and verifiable information about the quality of a country’s policies through a SABERͲ School Health Questionnaire. This dataͲcollecting instrument helps to facilitate comparative policy analysis, identify key areas to focus investment, and disseminate good practice and knowledge sharing. This holistic and integrated assessment of how the overall policyinacountryaffectsyoungchildren’sdevelopment is categorized into one of the following stages, representing the varying levels of policy development thatexistamongdifferentdimensionsofschoolhealth: 1. Latent:Noorverylittlepolicydevelopment 2. Emerging:Initial/someinitiativestowardspolicy development. 3. Established:Somepolicydevelopment Advanced:Developmentofacomprehensive policyframework    SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 5 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014     Figure3:Policygoalsandpolicyleversforschoolhealth                               SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 6 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   Findings reasons for absences; identified problems with existing school health services; and identified practicable Policy Goal 1: Health interventions to improve children’s health, nutrition, school attendance, and educational achievement. Related School Policies in However, troubles arise because the current Uganda  unpublished draft of the school health policy 37 , the program design, and program implementation are not PolicyLevers: aligned with the thematic and geographic needs x NationalͲlevelpolicy identified in the situation analysis. Some of Uganda’s x CoordinatedimplementationofanationalͲlevel major health and nutrition challenges include a lack of policy adequate resources and personnel to implement school x Governanceofthenationalschoolhealthpolicy health programs, a high level of child and maternal x Qualityassuranceofprogramming undernutrition, and a high level of micronutrient x Gendermainstreaming deficiency. 38 Changes need to be made as part of a strategic effort based on evidence of good practice. HealthͲrelated school policies provide structure for a Ugandaisusingtheresultsofthesituationanalysisstudy safe,secure,andnonͲdiscriminatoryschoolenvironment. toinformthedraftedschoolhealthpolicy. These policies also convey government commitment to school health. Although there are different avenues Uganda should also set a monitoring and evaluation countries may take for the delivery of school health and (M&E) plan to monitor school health programming. nutrition, a review of best practices in school health There is currently no approved M&E plan at either the programming suggests that there are certain roles national or community level; therefore, no systematic consistently played by governmental and nonͲ school health program evaluations are conducted. An governmentalagencies. effective M&E system provides tools to monitor school health programming and evaluates the effectiveness of Uganda has published a national poverty reduction these programs in achieving their health and education strategy 35 , but school health (i.e., schoolͲbased health goals.IntegratingsuchanM&Eplanintoawidernational andnutritionservices,skillsͲbasedhealtheducation,and M&Esystemwouldensureasustainablesystemthatcan access to a clean and safe school environment) is not be assessed with the broader national goals of the included in it. Furthermore, Uganda does not have a educationsector.Ugandahasalotofworktodoinorder published national policy on school health, although a to achieve this level of sophistication in an M&E plan. draft was developed by regional and national However,recognitionofgenderdimensionsdoesexistin stakeholders(districtmedicalofficers,districteducation anationaleducationpolicy,eventhoughthispolicyisnot officers, district inspectors of schools, civil society, fully implemented at the national level. There is a private sector, local development partners, and nonͲ separate M&E mechanism in place to monitor gender governmentalorganizations).36 mainstreaming, foreshadowing future acknowledgementsofgenderequalityissuesinschool. There is neither a national school health steering committee to coordinate a school health policy nor a national budget line for school health. Without this budget, there can be no plan to disburse funding to variousareasinneed. Uganda has performed a situation analysis of the developmentofthecountry’sschoolhealthprograms.It has identified major health and nutrition problems of schoolͲage children; quantified school participation and  35 37 IMF,2010. WHO,2011. 36 GovernmentofUganda.“UgandaNutritionActionPlan2011Ͳ2016”. GovernmentofUganda,2010. 38  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 7 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   1. HealthͲRelatedSchoolPoliciesisEMERGING 1H.Gender Genderdimensionof dimensionofHealth healthisaddressedin Indicator Score Justification addressedin  publishededucation 1A.Schoolhealth Publishednational nationaleducation policyyetthispolicyis includedin povertyreduction policy notfullyimplemented nationalͲlevel  strategyavailableyet atnationallevel povertyreduction schoolhealthnot  strategyor includedinPRSP   equivalentnational policy 1B.Publishedand Nationalrecognitionof distributednational theimportanceof policycoversall  schoolhealthbut fourcomponentsof policynotpublished FRESH 1C.Published Nopublishednational nationalpolicy policyonschoolhealth involvesa  multisectoral approach 1D.Multisectoral Anymultisectoral steeringcommittee steeringcommittee coordinates  coordinationefforts implementationof arecurrentlynonͲ anationalschool systematic healthpolicy 1E.Nationalbudget Nationalbudgetline line(s)andfunding doesnotexist; allocatedtoschool  mechanismsto health;fundsare disbursefundsfor disbursedtothe implementationalso implementation donotexist levelsinatimely andeffective manner 1F.Situation Situationanalysis analysisassesses conductedthat needforinclusion  assessesneedfor ofvariousthematic inclusionofvarious areas,informing thematicareas;does policy,design,and notidentifyissues implementationof requiringfurther thenationalschool investigationor healthprogram programcostanalysis suchthatitis targetedand evidenceͲbased 1G.Monitoringand Systemsarenotyetin Evaluation(M&E) placeforM&Eof  implementationof schoolhealth programming  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 8 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   stigmatization: orphanhood, HIV, physical disabilities, PolicyGoal2:SafeSupportive and mental disabilities. Uganda is in the process of School Environments in coveringstigmainalifeskillscurriculuminallschools. Uganda  National standards and guidelines have not been developed or published on how to address institutional PolicyLevers: violence. Uganda does not systematically provide psychosocial support to teachers and students who are x Physicalschoolenvironment affected by trauma due to shock. Some schools do have x Psychosocialschoolenvironment psychosocialsupportavailabletoteachersandstudents, A safe, supportive school environment is imperative for schoolͲbased psychosocial interventions, and referral schoolchildren who spend a significant part of their day services, yet this support is far from evenly spread in school. Lack of safe water and other adequate throughoutthecountry.  sanitation measures contribute to high rates of disease and mortality among schoolͲage children. On top of disease control, a safe psychosocial environment also affects students positively, fostering the health, wellͲ being and learning potential of adolescents. Children should be mentally healthy on top of being physically healthy, so a supportive learning environment with a sense of personal security, fully genderͲsensitive conditions, and healthy relations between pupils and teachers all contribute to the behavior and learning opportunityofstudents. National standards for the provision of safe water and sanitationfacilities39inschoolshavebeenset,butthese standards have not been implemented in most schools. National guidelines regarding hand washing or hand washing stations in schools have been incorporated in the yetͲtoͲbeͲapproved Guidelines for School Feeding40 inUPEandUPPETSchoolsystems. There are no national guidelines on the safety of school infrastructure, and the mechanisms to monitor the maintenance of safety standards that have been nationally recognized are not fully established. No mechanisms are in place to update old school buildings to meet national safety standards, and there is no systematic mobilization of the school community and local stakeholders to maintain a healthy school environment. Apart from physical necessities, a positive psychosocial schoolenvironmentalsoneedstobecreatedtoimprove school attendance and students’ educational accomplishments. Uganda faces many sources of  39 GovernmentofUganda.MinistryofHealth.“NationalSanitationGuidelines”. “NationalSchoolFeedingGuidelinesforUganda”.2009. 40  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 9 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   2.Safe,SupportiveSchoolEnvironmentsisEMERGING   Indicators Score Justification   2A.Provisionofsafe Nationalsurveys waterinschools havebeen  conductedto assesswhether schoolsmeet standardsforsafe waterand implementation plansareinplace toachievethese standards 2B.Provisionof Nationalstandards sanitationfacilities establishprovision   forsanitation facilitiesyetmost schoolsdonothave adequatesanitation facilities 2C.Provisionofsound Nationalstandards schoolstructuresand forregulating schoolsafety  safetyofschool infrastructureare setyetsafety standardsarenot fullyestablished;no mechanismsto updateoldschool buildings 2D.Issuesof Stigmaiscoveredin stigmatizationare lifeskillseducation, recognizedand  preͲandinͲservice addressedbythe teachertraining educationsystem providedyet schoolͲlevelpolicy toaddressbullying duetostigma insufficient althoughall mechanismsin processor established 2E.Protectionof Nationalstandards learnersandstaff onhowtoaddress fromviolence  violenceinschools  arelacking 2F.Provisionof Somepsychosocial psychosocialsupport supportisavailable toteachersand  tolearnersand studentswhoare teachersbut affectedbytrauma coverageisnot duetoshock universal  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 10 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   3.SchoolͲBasedHealthandNutritionServicesis PolicyGoal3:SchoolͲBased EMERGING Health and Nutrition Indicators Score Justification  3A.TheschoolͲbased Situationanalysis ServicesinUganda healthandnutrition hasbeen servicesidentifiedin  undertakenbutnot PolicyLevers: thesituationanalysis allinterventions x SchoolͲbaseddeliveryofhealthandnutrition andoutlinedinthe havebeen services nationalpolicyare implementedand x SchoolͲbasedscreeningandreferraltohealth beingimplemented scaledup systems 3B.Remedialservices Situationanalysis (e.g.,refractiveerrors, assessesneedfor Schools that take simple health interventions to dental,etc.)  schoolbased effectively address diseases and health concerns such as  screeningand malnutrition, shortͲterm hunger, micronutrient referraltoremedial services;outlinedin deficiencies, vision and hearing impairments, and worm nationalpolicyyet infections largely mitigate burdens and constraints that noactionto thesediseasesbringtoschoolchildren. implementthese servicesinplaceyet Uganda has developed costͲeffective and schoolͲbased 3C.Adolescenthealth Anyreferralsof healthinterventionsbasedontheneedsidentifiedinthe services pupilstotreatment situation analysis from the previous policy goal.  systemsfor However, not all interventions identified have been adolescenthealth implementedandscaledup. servicesoccurnonͲ systematically SchoolͲbasedscreeningandremedialserviceshavebeen  identified in the situation analysis and outlined in the  national policy, yet there has not been any action to implement these services. There is also no preͲ or inͲ   service teacher training provided to ensure smooth implementation of these services, or provision for teacher training for referral of adolescents to appropriateadolescenthealthservices.          SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 11 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   4.SkillsͲBasedHealthEducationisEMERGING Policy Goal 4:  SkillsͲBased Indicators Score Justification HealthEducationinUganda 4A.Provisionofbasic, Nationalschool   accuratehealth,HIV, curriculumcovers nutritionandhygiene  somebutnotall PolicyLevers: informationinthe theissues schoolcurriculumthat identifiedin x KnowledgeͲbasedhealtheducation isrelevanttobehavior situationanalysis; x AgeͲappropriateandsexͲspecificlifeskillseducation change preͲandinͲservice forhealth trainingisbeing provided A comprehensive health education aims at developing 4B.Participatory Somelifeskills knowledge,attitudes,andlifeskillsthatarenecessaryfor approachesarepart educationistaking health promoting behaviors. There is a growing ofthecurriculumand  placeinsome recognition of and evidence for the important role of areusedtoteachkey schoolsusing psychosocial and interpersonal skills in the healthy ageͲappropriateand participatory development of young people. 41 Skills like selfͲ sexͲspecificlifeskills approaches,butit management, communication, decisionͲmaking, and forhealththemes isnonͲuniformand doesnotcoverall problemsolvingcanstrengthentheabilityofadolescents ofthelifeskills to protect themselves from health threats and adopt positiverelationships.  To view the scores for all indicators and policy goals in Uganda’s national school curriculum is partially onetable,pleaserefertoAppendix1. developed, covering some but not all the issues identifiedinthesituationanalysis.Thecurriculumcovers personal hygiene, food and nutrition, growth and development,familylife,alcoholandsubstanceuse,HIV, AIDS, and other STDs. All schools are teaching this curriculum, and Uganda provides preͲ and inͲservice training to teachers who teach this curriculum. HealthͲ related knowledge is integrated into school examinations to track the progress of students. Participatory approaches to teach ageͲappropriate and sexͲspecific life skills for health behaviors are not integrated into the national curriculum. These life skills are,however,includedinpartoftheschoolcoͲcurricular program (clubs) and incorporated in a document titled PresidentialInitiativeonAIDSandSocialCommunication toYouth(PIASCY).42      41 WHO,2003. 42 GovernmentofUganda.MinistryofEducation&Sports.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 12 UGANDAۣSCHOOLHEALTH  SABERCOUNTRYREPORT|2014   Conclusion  Basedontheabovefindings,schoolhealthinUgandacan be seen as emerging. There are areas that could be strengthened. The following policy options represent areaswhereschoolhealthcouldbeimprovedinUganda, basedontheconclusionsofthisreport. PolicyOptions: x Incorporate school health in national strategies such as the Poverty Reduction Strategic Plan (National Development Plan, Uganda Vision 2040). x Finalizethedraftschoolhealthpolicyandputin place a National School Health Steering Committee to coordinate its implementation acrossallrelevantsectors. x Include school health line items in both the educationandhealthbudgets. x Createandimplementnationalstandardsforthe provision of water and sanitation facilities in schools, including a monitoring and evaluation plan. x Create and implement national guidelines for hand washing and school infrastructure safety, as well as the appropriate monitoring mechanisms. x Create plan to monitor and encourage activities aroundpsychosocialsupportinschools x Scale up provision of evidenceͲbased schoolͲ basedhealth andnutritionservicesasidentified inthesituationanalysis. x Create and implement teacher training to promote school health interventions, including screeningandreferralsystems. x Create a national life skills curriculum and implement through teacher training and classroomteaching. x Include an assessment of health and life skills educationinnationalexaminations.   SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS 13 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  Appendix1 Table1.LevelsofDevelopmentofSABERSchoolHealthIndicatorsandPolicyGoalsinUganda Systems Approach for Better Education Results: Benchmarks for Uganda on School Health Policy Framework STAGE OVERALL POLICY LEVER INDICATOR SCORE PER Latent Emerging Established Advanced DOMAIN Policy Goal 1: Health-realted school policies School health included in School health is included in School health discussed by national-level poverty School health not yet the national poverty members and partners School health included in reduction strategy or included in national-level reduction strategy or in the during preparation of PRSP the PRSP or equivalent equivalent national policy, poverty reduction strategy equivalent but not included in final national policy accompanied by targets or equivalent national policy national policy PRSP and/or milestones set by the government Comprehensive approach Published national policy to all four areas promoting that covers some aspects Published national policy inclusion and equity; almost of all four components of National recognition of the that covers some but not all all regional and school-level Published and distributed FRESH; almost all regional importance of school health four components of FRESH stakeholders have copies National-level policy national policy that covers and school-level exists but a national policy (e.g. a policy on HIV in of the national school that addresses school all four components of stakeholders have copies has not been published as education only); some health policy and have health FRESH of the national school yet regional and school-level been trained in its health policy and have stakeholders have copies implementation and written been trained in its school-level policies exist implementation that address school health Published national policy National recognition of the jointly by both the importance of a Published national policy by Published national policy by education and health Published national policy is EMERGING multisectoral approach to the education or health the education and health sectors that addresses multisectoral in its school health exists but a sector that addresses sectors that addresses school health and includes approach national policy has not school health school health other relevant sectors (e.g. been published as yet water, environment, agriculture) Multisectoral steering committee from education, Sectoral steering Multisectoral steering Coordinated A multisectoral steering health, and one or more Any multisectoral steering committee from education committee from both implementation of a committee coordinates other relevant sectors (e.g. committee coordination or health coordinates education and health national-level policy implementation of a school water, environment, efforts are currently non- implementation of a coordinates implementation that addresses school national health agriculture) coordinates systematic national school health of a national school health health policy. implementation of a policy policy national school health policy   SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS       14 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  National budget line and funding for school health exists in health, education, National budget line and National budget line and and one or more other A national budget line(s) A national budget line or funding for school health funding for school health sectors; school health and funding allocated to funding does not yet exist exists in both the health Governance of the exists in either the health or funds are disbursed to the school health: funds are for school health; and the education sectors; national school health education sector; school implementation levels in a disbursed to the mechanisms do not yet school health funds are policy health funds are disbursed timely and effective manner implementation levels in an exist for disbursing funds to disbursed to the to the implementation and implementers have the effective and timely manner the implementation levels implementation levels in a levels intermittently capacity to plan and budget timely and effective manner as well as request resources from the central level Situation analysis Situation analysis conducted that assesses conducted that assesses A situation analysis the need for the inclusion of Incomplete situation the need for the inclusion of assesses the need for A situation analysis has not various thematic areas, analysis that assesses the various thematic areas; inclusion of various yet been planned to assess along with costings; policy, need for the inclusion of policy, design, and thematic areas, informs the need for the inclusion of design, and comprehensive various thematic areas; implementation of these policy, design, and various thematic areas and implementation of these policy, design, and thematic areas are based implementation of the inform policy, design, and thematic areas are based implementation of some on evidence of good national school health implementation of the on evidence of good thematic areas are based practice and are targeted program such that it is national school health practice and are targeted on evidence of good according to situation targeted and program according to situation practice analyses of what thematic evidence-based analyses of what thematic Quality assurance of area interventions to target area interventions to target programming in which geographic areas in which geographic areas The M&E plan for school health is integrated into The M&E plan for school national monitoring or A M&E plan exists for health is integrated into information management Systems are not yet in school health programming national monitoring or systems and data collection place for M&E of and data collection and information management Monitoring and Evaluation and reporting occurs implementation of school reporting occurs systems and data collection recurrently at national, health programming intermittently especially at and reporting occurs regional and school levels; national level recurrently at national and baseline carried out and regional levels program evaluations occur periodically Health dimension of gender is addressed in published Gender Health dimension of gender Health dimension of gender Health dimension of gender Gender dimension of health education policy, mainstreaming in the is not yet formally addressed in national is addressed in published addressed in the national implemented nationally, national school health addressed in national education policy but education policy and is education policy and the M&E mechanism policy education policy implementation is uneven implemented nationally includes oversight of the gender mainstreaming     SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS       15 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  Policy Goal 2: Safe, supportive school environments The need for safe water Most schools have water The need for provision of provision in all schools is that is accessible, of good safe water is Fresh potable water is Physical school recognised, standards have quality and adequate Provision of water facilities acknowledged, but available to students in environment been established, but supply; facilities are standards are absent, and most schools national coverage has not regularly maintained and coverage is uneven been achieved monitored The need for provision of The need for provision of sanitation facilities in all Most schools provide sanitation facilities is schools is recognised, Sanitation facilities are adequate sanitation Provision of sanitation acknowledged, but standards have been available to students in facilities and these facilities facilities standards are absent, and established, but national most schools are regularly monitored and coverage is uneven coverage has not been maintained achieved Sound school structure standards are set – both national and local and Construction and National and local New schools being built coverage is universal for Provision of sound school maintenance of school standards for sound school have sound structures and new builds and an update structures (including buildings is unregulated structures are fully school safety issues are program is in place for accessibility for children and national standards are implemented and coverage taken into account, but older buildings; teachers, with disabilities) lacking on what constitutes is universal; building coverage is not universal schoolchildren, families and and school safety sound school structures structures are regularly among older schools other local stakeholders are and school safety monitored and maintained mobilized to achieve and sustain a healthy school environment Stigma is covered in life EMERGING skills education, pre- and Stigma is covered in life in-service teacher training Some schools are skills education, pre- and are being provided effectively responding to Any responses to issues of in-service teacher training universally, bullying as a Issues of stigmatization are stigma issues, but stigmatisation in schools are being provided result of stigma is recognized and addressed coverage is not universal; are currently non- universally, and bullying as effectively dealt with at the by the education system in-service teacher training systematic a result of stigma is school level, and support on stigma issues is being effectively dealt with at the groups responding to provided school level specific stigma issues are in place for both learners and teachers National standards and National standards on how guidelines on how to to address some forms of address some forms of Mechanisms are in place to National standards on how institutional violence in Protection of learners and institutional violence in respond to all forms of to address violence in schools are in place, staff against violence schools are published and institutional violence in schools are lacking guidelines are being disseminated; pre- and in- schools developed, and in-service service teacher training are training is being provided being provided universally   SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS       16 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  Effective school-based Available psychosocial intervention for supporting support for learners and students’ psychosocial well- teachers is mobilised being is developed and (either in school or through there is provision of Provision of psychosocial Provision of psychosocial Some psychosocial support referral services) and there appropriate psychosocial support to teachers and support for learners and is available to learners and is provision of appropriate support activities for students who are affected teachers affected by teachers either in school or psychosocial support teachers and students in by trauma trauma due to shock is non- through referrals but activities for teachers and temporary learning spaces due to shock uniform coverage is not universal students in temporary and in child-friendly spaces learning spaces and in for young children and child-friendly spaces for adolescents; impact on young children and psychosocial wellbeing and adolescents cognitive function is being monitored Policy Goal 3: School-based health and nutrition services Situation analysis has been All of the school-based undertaken, identifying cost-effective and The school based delivery Situation analysis has been cost-effective and appropriate health and of health and nutrition A situation analysis has not undertaken that assess the appropriate school-based nutrition services identified School-based delivery services identified in the yet been undertaken to need for various school- health and nutrition in the situation analysis and of health and nutrition situation assess the need for various based health and nutrition interventions, some of outlined in the national services analysis and outlined in the school-based health and services but systematic which are being policy are being national policy are being nutrition services implementation is yet to be implemented and taken to implemented and taken to implemented underway scale in a targeted manner scale in a targeted manner in the available budget in the available budget All of the school-based Situation analysis has been cost-effective and undertaken, identifying appropriate screening and Situation analysis has been A situation analysis has not those cost-effective and referral to remedial services undertaken that assess the yet been undertaken to appropriate school-based identified in the situation School-based need for school-based assess the need for school- screening and referral to analysis and outlined in the screening and referral Remedial services screening and referral to based screening and various remedial services national policy are being to health systems various remedial services EMERGING referral to various remedial that are being taken to implemented and taken to but implementation is services scale in the available scale in the available uneven budget; in-service teacher budget; pre- and in-service training is being provided teacher training are being provided Pre- and in-service training Teacher training for referral Any referrals of pupils to Teacher training for referral of teachers for referral of of pupils to treatment treatment systems for of pupils to treatment pupils to treatment systems Adolescent health services systems for adolescent adolescent health services systems for adolescent for adolescent health health services with referral occur non-systematically health services services with referral ongoing ongoing     SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS       17 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  Policy Goal 4: Health education Some health, HIV, nutrition Curriculum and/or hygiene information Curriculum comprehensively covers is included in the comprehensively covers health (linked to the health Provision of basic, accurate Some schools are teaching curriculum, but it may not health (linked to the health issues identified in the health, HIV and AIDS, some health, HIV, nutrition be comprehensive; in- issues identified in the situation analysis), HIV, Knowledge-based nutrition and hygiene and hygiene information, service teacher training is situation analysis), HIV, nutrition and hygiene health education information in the but coverage is not being provided, and the nutrition and hygiene knowledge; pre- and in- school curriculum relevant universal nor is the majority of schools are knowledge; pre- and in- service training is being to behavior change information provided teaching the curriculum service training is being provided; all schools are covered health information, provided; and all schools teaching the curriculum; but coverage is not are teaching the curriculum and the knowledge is universal covered in school exams Participatory exercises to teach life skills for health Participatory approaches behaviours are part of the Participatory exercises to are part of the national national curriculum; pre- teach life skills for health curriculum; some of the key and in-service training is Some life skills education is behaviours are part of the EMERGING Participatory approaches life skills for health themes being provided; materials taking place in some national curriculum; pre- are part of the curriculum are covered in the for teaching life skills for Age-appropriate and schools using participatory and in-service training is and used to teach key age- curriculum; in-service health in schools are in sex-specific life skills approaches, but it is non- being provided; and appropriate training is being provided; place and made available education for health uniform and does not cover materials for teaching life and sex-specific life skills and teaching of the and teaching is ongoing in all of the life skills for health skills for health in schools for health themes participatory approaches is most schools; and school themes are in place and made taking place in the majority curricula guidelines identify available and teaching is of schools, but is not specific life skills for health ongoing in most schools universal learning outcomes and measurement standards, including examinations      SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS       18 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  Acknowledgements UPE UniversalPrimaryEducation ThisSABERͲSchoolHealthreportwaspreparedfromthe UPPET UniversalPostPrimaryEducationandTraining SABERͲSchool Health questionnaire completed by staff of the Ministry of Education and Sports, the National WFP WorldFoodProgramme Planning Authority, and the Ministry of Water and Environment.  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Missell, and https://extranet.who.int/nutrition/gina/en/node/1 A.Valyasevi.1989.“IronDeficiencyandEducational 4801. Achievement in Thailand.” American Journal of WHO(WorldHealthOrganization).2003.“Skillsfor ClinicalNutrition50m(3suppl):687Ͳ96. Health,SkillsͲBasedHealthEducationIncludingLife Powell, C.A., P.S. Walker, S.M. Chang, and S.M. Skills:AnImportantComponentofaChildͲ GranthamͲMcGregor. 1998. “Nutrition and Friendly/HealthͲPromotingSchool.”Information Education: A Randomized Trial of the Effects of SeriesonSchoolHealth.WHO,Geneva.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS  20 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015  WorldBank.2014a.WorldDevelopmentIndicators 1990Ͳ2013[statistics].“Uganda”.Availablefrom theWorldBankWorldDevelopmentIndicators database. WorldBank.2014b.EducationIndicators1990Ͳ2013 [statistics].“Uganda”.AvailablefromWorldBank EdStatsdatabase. WorldBank,2011.Strengtheningschoolbased managementinUganda.Analysisoftraining programsandinspectionreportsforemerging issues.Inceptionreport.SubmittedbyAsiimwe JohnBosco,March2011.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS  21 UGANDAۣSCHOOLHEALTHPOLICIES    SABERCOUNTRYREPORT|2015    www.worldbank.org/education/saber The Systems Approach for Better Education Results (SABER) initiative collectsdataonthepoliciesandinstitutionsofeducationsystemsaround the world and benchmarks them against practices associated with student learning. SABER aims to give all parties with a stake in educational results—from students, administrators, teachers, and parents to policymakers and business people—an accessible, detailed, objectivesnapshotofhowwellthepoliciesoftheircountry'seducation systemareorientedtowardensuringthatallchildrenandyouthlearn.  This report focuses specifically on policies in the area of School Health Policies. ThisworkisaproductofthestaffofTheWorldBankwithexternalcontributions.Thefindings,interpretations,andconclusionsexpressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territoryortheendorsementoracceptanceofsuchboundaries.  SYSTEMSAPPROACHFORBETTEREDUCATIONRESULTS  22