Abstract
Modern schools do their best to motivate young people to live fulfilling, healthy and productive lives and the United Nations has put school education at the heart of the Millennium Development Goals. The context of education in schools is changing, but there is evidence from across the world that school health promotion can make a difference to health and education outcomes. The International Union for Health Promotion and Education (IUHPE) has recognized this potential in schools and, for the last five years in its work globally, has been actively engaged in strengthening efforts through successful partnerships. This commentary explores aspects of global partnerships in school health and the progress of the IUHPE’s leadership and partnership work in school health promotion. It also provides some reflections on what has been achieved to date and what might lie ahead in school health promotion globally.
Introduction
This commentary explores global partnerships in school health and the progress of the International Union for Health Promotion and Education’s (IUHPE) leadership and partnership work in school health promotion. It also provides some reflections on what has been achieved to date and what might lie ahead in school health promotion globally.
Progress in global school health partnerships
We cannot predict the future. When two of the authors of this paper started working in health education in the early 1980s the term health promotion had not been reborn in its modern form, Western countries thought complacently that they were close to conquering infectious diseases, and the idea that in a generation as many people would be overfed rather than malnourished would have been ridiculed by many. How much has changed since then. In addition, the urbanization of the planet and the world of instant electronic communication inhabited by most young people have radically changed the social settings in which modern schools do their best to motivate young people to live fulfilling, healthy and productive lives.
Partnerships for broad dissemination efforts – evidence of school health promotion effectiveness
However, we do not need a crystal ball to predict that school health promotion can make a difference globally to health and education outcomes. In fact, evidence is available and being actively disseminated by the IUHPE, the Centers for Disease Control and Prevention (CDC) and other school health partners globally. i IUHPE has fully recognized the potential of schools, and for the last five years in its work globally it has had a successful partnership agreement with the CDC in Atlanta, USA.
Objectives of the IUHPE / CDC collaboration
The long-term objectives of the collaboration with CDC have been:
to build the capacity of both the health and education sectors to undertake initiatives in school health promotion that are based on evidence of effectiveness and which enhance the fundamental role of school education;
to develop and disseminate resources/strategies in three areas:
Advocacy, using evidence of outcomes;
Guidelines for Promoting Health in Schools, setting out the principles of health promotion in schools and supporting school health planning and implementation; and
Implementation and sustainability.
to initiate and lead debates, presentations, consultations and discussions on school health to complement and add value to the work at IUHPE global, regional and other sponsored conferences and meetings, and through the International School Health Network (ISHN);
to build the capacity of government ministers of health and education to form effective partnerships to increase the number/proportion of health-promoting schools;
to collaborate with other organizations, such as WHO, UNICEF, other non-governmental organizations (NGOs) and research institutes; to identify the gaps and/or overlap in research and evaluation in school health promotion; and to develop a plan to address those issues.
Collaboration outcomes: key global resources and tools to inform adapted and tailored practice around the world with a specific focus on low- and middle-income countries
The first three resources produced from this work are now well known globally, with translations aiding dissemination and practical use. These resources are:
Broad accessibility and dissemination of resources
Dissemination efforts
In the course of the five-year agreement, wide dissemination of these resources and key concepts and principles of whole-of-school approaches was achieved through:
translation into many languages (Arabic, Chinese (traditional Chinese and simplified Chinese), English, French, Italian, Japanese, Portuguese, Russian and Spanish) to ensure broad accessibility and culturally sensitive language versions and availability on various electronic resources including the IUHPE website;
referencing of documents in publications (4–6) and other international project efforts ii and cross-referencing of the content of each of the products to promote each other and encourage a systematic approach to school health promotion globally;
broad dissemination to key stakeholders (Education Development Center, Inc.; Education International; Save the Children; Child to Child Trust, Partnership for Child Development; Salaam Bombay Foundation; Health Related Information Dissemination Amongst Youth – Student Health Action Network (HRIDAY – SHAN); Thai Health Promotion Foundation; amongst others);
via the IUHPE network, CDC key contacts and other various partners and networks in the Western Pacific, Asia, Africa, Europe, Latin America, North America and the Eastern Mediterranean region (7);
numerous international workshops held under the auspices of IUHPE in various regions of the world: New Zealand 2008, Singapore 2008, Tampa, USA, 2008, Torino, Italy 2008, Banff, Canada, 2009, Perth, Australia, 2009, Vilnius, Lithuania, 2009, Hong Kong 2009; Geneva 2011, Quebec 2011 and Taiwan, 2012.
Some examples of how the IUHPE / CDC collaboration efforts informed practice globally over the years
The efforts conducted under the IUHPE / CDC collaboration with the former Division of Adolescent and School Health (DASH) have enabled the dissemination of key whole-of-school concepts globally and informed policy and practice in various countries with key resulting resources:
informing programme and policy development as well as resource allocation in local regions and in local government areas in a number of countries in Asia, the Western Pacific and Africa (e.g. informing the drafting of several programmatic and strategic documents in Benin both at the Ministry of Health and at the WHO Benin office);
informing advocacy and dialogue with ministries and policy and decision makers in Quebec;
being used in training through courses, workshops and seminars for teachers, health promoters, school principals, school nurses and public health specialists. In addition, being used in undergraduate and post-graduate education of teachers in school health in universities. This has been reported in diverse countries of the Asian, Western Pacific, European and Latin American regions – namely in Hong Kong, Taiwan, France, Argentina, Uruguay, Chile, Brazil, Colombia and Peru;
being used as the basis to inform key technical efforts. The documents were influential in a report produced for WHO Eastern Medite-rranean Region of WHO (EMRO) – a contextual paper associated with the production of a practical assessment tool for WHO member states in the region. Technical groups collaborating with the Pan American Health Organization in developing guidelines and tools for advancing the health-promoting schools initiative in the Americas have also used these documents as a main reference for their work.
Though there was no reported experience of use by Canadian first nations, Inuit communities operate educational systems outside of the 10 big provincial jurisdictions. As part of these separate efforts, they are developing culturally appropriate curricula and pedagogy that is reflective of Inuit cultural values – a very comprehensive and holistic approach to well-being, and this fully supports the essential element for health-promoting schools as outlined in the IUHPE documents.
New resources
Two additional resources from this partnership between IUHPE and CDC have just been finalized (8,9). These are widely accessible, and it is expected that these will continue to contribute to strengthening efforts initiated under the partnership.
Facilitating Dialogue between the Health and Education Sectors to Advance School Health Promotion and Education
A first document on Facilitating Dialogue between the Health and Education Sectors to Advance School Health Promotion and Education (8) aims to facilitate better dialogue between the health and education sectors. It has become evident that sustaining health-promoting schools at national level requires a continuous active commitment and demonstrable support by governments, with two or more ministries/sectors working in partnership. Our experience suggests that a lack of understanding between health, education and other relevant ministries is often a block to progress in many countries. With this goal in mind, this briefing document supports the advocacy and policy development work of health-promoting school co-ordinators working at national and/or regional/state level.
It explores issues such as: perceptions and concepts of health education and health promotion, sector priorities, language, leadership, budgetary control and managing change, amongst others. It offers practical advice based on examples of successful practice. Aspects of the proposed document were explored with participants in a workshop during the international event on Health-Promoting Schools in Montreal, Canada in November 2011. Participants at that workshop provided specific advice and examples to strengthen the main thrust of the work.
Monitoring and Assessing Progress in Health-Promoting Schools: Issues for Policy Makers to Consider
A second document for the dedicated IUHPE webpages on Monitoring and Assessing Progress in Health-Promoting Schools: Issues for Policy Makers to Consider (9) explores the different types of tools that are available at present for monitoring and assessing progress in health-promoting schools and offers a brief review of the practical issues that practitioners have had to overcome in developing such tools. It is designed to assist countries in an early stage of monitoring progress towards health-promoting schools.
It describes the barriers to the effective implementation of inter-sectoral partnerships in countries of the world, with government health ministries and education ministries often expressing a desire to co-operate but in effect often working separately with different priorities and goals. Some of the issues explored are:
different perceptions and concepts of health education and health promotion in the health and education sectors;
different sector priorities;
misunderstandings due to different use of technical language;
professional career issues – career advancement and promotion may be more linked to evidence of leadership than managing a partnership with other sectors; and
budgetary control – there may be tensions between those who are in a position to be the best networkers and those who control the budget.
Based on examples of success, suggestions are made for overcoming these barriers, and how genuine partnership can work leading to more effective management of health promotion in schools, including effective monitoring and assessment of progress (9).
The document highlights several initiatives at the international level such as The Rapid Assessment and Action Planning Process (RAAPP) (10), which is a country-driven and evidence-based method which enables ministries of education and health to assess and improve their capacity to promote health through schools. Given the link between health and education, RAAPP is based on two concepts: Health-Promoting Schools (HPS) and Focusing Resources on Effective School Health (FRESH).
In addition the document makes reference to The Egmond tool (11), and this is provided in an appendix. It was developed from experience of the successes and challenges of 20 years of development work in Europe, including more than 10 years in The European Network of Health-Promoting Schools. It can be used flexibly in one-to-one interviews with key stakeholders as well as providing an agenda to structure group discussions.
The document concludes that the tools most likely to be successful and sustainable are ones that have considered ownership and cultural issues and therefore involved practitioners in their development (12).
The new IUHPE document (9) points out that in the early years of health promotion in schools it was mainly the health sector which took the initiative (1). It is now better understood that there is a need to be sensitive to the education system’s ways of working and methods of assessment. The consequence of this is a requirement for genuine partnership-working between the education and health sectors.
School Health and the Millennium Development Goals – progress and challenges
The United Nations has put school education at the heart of its Millennium Development Goals (MDG) (13). The second MDG goal relates to achieving universal primary education. The third MDG goal relates to promoting gender equality and empowering women, and one of the ways of achieving this is to ensure that girls get the same educational opportunities as boys.
Considerable improvement in enrolment in primary education has occurred, reaching 89 per cent in the developing world in 2008, and increasing by 18 percentage points in sub-Saharan Africa between 1999 and 2008. However, despite the second target being relatively modest, as it only applies to a basic education, it is not being met. The progress is insufficient to ensure that, by 2015, all 660 million young people who should be receiving an education will complete a full course of primary schooling.
In global terms, approximately 69 million school-age children were not going to school in 2008, a significant improvement from 106 million children in 1999. Almost three-quarters of children out of school are in sub-Saharan Africa (31 million) or Southern Asia (18 million). Drop-out rates in sub-Saharan Africa remain high. Achieving universal primary education requires more than full enrolment. It also means ensuring that children continue to attend classes. Only 87 out of 100 children in the developing regions complete primary education.
This issue casts a shadow over all our work in school health promotion if we have reducing inequalities as a major priority. Health-promoting schools require children to attend as a prerequisite for success. It is both a political and economic issue, and all international agencies and governments need to keep up the pressure to ensure the gains that have been achieved are sustained and that all school-age children receive a basic education wherever they are born. This will require a large investment in infrastructure and in the training of teachers.
Conclusions
We have the evidence – let’s use it and continue efforts
For the great majority of children who do attend school we have enough evidence, skills and experience to determine what needs to be done in the context of health-promoting schools. We now understand the nature of the prerequisites for effective partnerships between the health and education sectors. In fact, experiences of specific countries and international programmes are demonstrating that it is achievable if there is a political will to support a partnership approach. We have to continue to translate this understanding into policies and political action.
Partnerships founded on beneficial relationships – an essential ingredient to successful international efforts
There is now a high level of international co-operation in the sharing of these ideas, challenges and evidence relating to school health promotion. In addition to the networks that exist on all continents, there is the unifying work of IUHPE and other agencies. A special mention should be given to the work of the ISHN, set up by Douglas McCall in Canada. This global network has recently been involved in a significant series of webinars sharing both evidence and experience in regard to implementation, capacity and sustainability issues in school health. These have covered topics such as capacity and capacity-building, systems thinking, inter-agency policies, collaboration and leadership and evidence-based practices in complex systems. In addition, the work of Carmen Aldinger and colleagues at the Educational Development Center in Boston, USA, resulted in the production of Case Studies in Global School Health Promotion: From Research to Practice. This publication provides evidence and inspiration of what has been achieved globally and gives pointers for future development needs and practice (14).
In India, the country with the world’s biggest population of school-age children, colleagues such as Padmina Somani at The Salaam Bombay Foundation work tirelessly towards empowering children to live their life free from the threat of tobacco and to become confident, healthy adults.
In the important area of teacher training, there is an on-going collaborative international study looking at teacher education and health education, led by Didier Jourdan, Professor at Blaise Pascal University in France, with Patricia McNamara of the University of Limerick in Ireland.
These are some of the many partners that have enabled and facilitated IUHPE and CDC efforts over recent years. It will be important for all partners to encourage the rapid uptake and use of all the documents produced by the partnership agreement with CDC, to ensure that developments in countries new to this work are based on sound evidence and the broad principles outlined in the published documents resulting from the collaboration.
IUHPE’s continuing commitment
IUHPE remains committed to facilitating dialogue between the health and education sectors in relation to school health promotion. In addition, it will continue to nurture partnerships with other relevant players in school health promotion such as WHO, continental HPS networks, ISHN, Education International, the CDC, and the Education Development Center.
The setting of schools has attracted great interest at the last three IUHPE global conferences. It is vital that we continue to build on this work at the 2013 event in Thailand to ensure that the progress to date is sustained. There are at least 660 million school-aged young people who can benefit from this vital work.
Footnotes
Funding
Some of the efforts described in this commentary were supported by the International Union for Health Promotion and Education (IUHPE) and the US Centers for Disease Control and Prevention (CDC) and received financial support from the United States Centers for Disease Control and Prevention (CDC), an Agency of the Department of Health and Human Services, under Cooperative Agreement Number CDC RFA DP07-708 on Building Capacity of Developing Countries to Prevent non-Communicable Diseases. The content of this commentary is solely the responsibility of the authors and does not necessarily represent the official views of CDC.