Revitalizing School Health Programs Worldwide
Habib Benzian, DDS, PhD, MScDPH
Each year, the Shils Fund recognizes outstanding activities that help improve oral health. The program is named in memory of Dr. Edward B. Shils, who led the Dental Manufacturers of America and Dental Dealers of America for more than 50 years. A 2010 Shils Award will be given to an innovative school health initiative called Fit For Schools Program (FFSP) in the Philippines. Such recognition in the US indicates the lessons that can be learned from a program initially tailored for another country. Health in a highly industrialized nation can be enhanced by heeding the FFSP principles used to craft an effective health promotion initiative. This evidence-based intervention is not exclusively an oral health initiative; it is an integration with other evidence-based health interventions and models a sustainable public-private partnership to advance positive health outcomes in socially responsible entrepreneurial ways. As the editor of this column in Compendium, I wish to applaud both leaders of FFSP: Dr. Habib Benzian and Dr. Bella Monse. The following article was written by the senior advisor, Dr. Benzian, who modestly refers to the program's receipt of another award from the World Bank, the United Nations Development Program, and the World Health Organization in 2009. To my knowledge, the presentation of that award was the first time a health promotion project led by dentists has ever received such high-level global recognition and was one of three projects so recognized for innovative solutions to global health in that year.
Lois K. Cohen, PhD
Paul G. Rogers Ambassador for Global Health Research
Children's health worldwide is threatened not only by acute conditions, such as diarrhea, pneumonia, and infectious diseases, but also by chronic diseases as exemplified by obesity and dental caries. Preventable infections and chronic diseases take a high toll on pediatric populations globally, with more than 200 million children not reaching their physical and cognitive potentials and an estimated 10 million dying per year from preventable causes.1-3
Consequently, international efforts to tackle childhood diseases have intensified, leading to a renaissance in the public health discourse as a most effective tool to improve pediatric health. For decades, health promotion and healthcare interventions in schools have been implemented in high-income countries, with oral health often among the first issues addressed. In many countries, particularly low- and middle-income, such programs remain limited in reach or are not sustainable financially. Efforts fade soon after implementation. Often, health and education decision-makers may underestimate the potential of schools to help promote public health.4
Innovation and Impact
The Fit for School Program (FFSP) is an integrated approach implemented in public elementary schools in the Philippines.5,6 It received an award as a winning solution from the World Bank, United Nations Development Program, and World Health Organization for "Innovation in Global Health" on the 6th World Day for South-South Cooperation in December 2009.
FFSP addresses the alarming disease burden of the pupil population throughout the Philippines. The innovative cornerstone is the use of existing school structures for implementing a package of preventive strategies called the Essential Health Care Program (ECHP). The ECHP consists of simple, evidence-based interventions that address the most prevalent diseases in these children: respiratory tract infections and diarrhea (the two leading causes of childhood mortality and morbidity), soil-transmitted helminth infections (approximately 60% of children have parasitic intestinal worms), and tooth decay (virtually all 6-year-olds have untreated caries). The program consists of:
- Supervised daily handwashing with soap
- Supervised daily brushing with fluoride toothpaste
- Semiannual deworming of all children by supervised ingestion of an albendazole tablet.
Implemented by school teachers, EHCP introduces measures aimed at sustainable healthy behavior and long-term health improvements. The FFSP costs only 50 cents for material and supplies per child each school year, an amount even governments with limited resources may be able to afford.
Since 2008, FFSP has been the national flagship program for school health. The German national development organizations Gesellschaft für Technische Zusammenarbeit and the Center for International Migration, as well as the private sector, contribute to FFSP by financing capacity development; the Philippine government covers the operational costs to ensure longer-term sustainability and ownership. The program reaches more than 1 million children. The plan is to cover at least 50% of the country's 12 million public elementary schoolchildren within the next 3 years. An independent charitable nongovernmental organization (NGO) leads the program's implementation, develops guidelines and templates, and advocates for required policy changes.
The program's three interventions have been practiced for decades and their effectiveness has been researched extensively. Handwashing with soap has been demonstrated repeatedly to be the most efficient, while inexpensive, way for helping prevent infectious diseases, such as diarrhea, which has been lowered by 30% to 50%. The benefits of deworming include a 20% reduction in the number of children with below-normal height and weight, as well as an 80% decrease in these earthworm parasitic infections.
Toothache is a common cause of school absenteeism in the Philippines. Brushing with fluoride toothpaste has been shown to reduce dental caries by 40% to 50% and proper implementation of this basic program is expected to improve school attendance by 20% to 25%.6,7
The combination of innovative, simple, and realistic interventions operated by teachers; the impact of evidence-based interventions reaching 1 million children; and leadership from a charitable NGO constitute essential factors for its success in the Philippines.
What Can Be Learned?
The internationally acclaimed innovative approach is based on the comprehensive large-scale implementation of existing policies and guidelines, resulting in significant action. The consistent application of simple principles, the pragmatic focus on practical realities at the school level, and the development of a supporting policy framework are essential elements for making a difference.
Some success factors are:
- Clear intersectoral agreements between health and education groups
- Transparent leadership and technical stewardship through an expert NGO
- Straightforward, evidence-based, and prevention-orientated interventions based on the real health needs of the children
- Activities in line with national and international policies and priorities, thus facilitating advocacy efforts and creating easy win-win situations
- Cost-effectiveness that allows for realistic sustained financing and allocation of government resources, making the program less dependent on external funding
- A focus on daily skills-based activities rather than on health education, thus creating life-long habits
- Full integration into daily tasks of education personnel, with a training and monitoring role for health personnel
- Motivation and satisfaction for all involved, resulting from the program's immediate and long-term benefits
Some of these factors apply to any school health program, even in high-income countries such as the United States. The Centers for Disease Control and Prevention, the American School Health Association, and many other organizations have a large body of policies, evidence, and guidance on school health. Yet, the focus is often on didactic teaching materials and simple knowledge transfer, which has a limited impact on long-term healthy behavior. Therefore, the FFSP was designed to engender lifelong daily hygiene habits through a skills-based approach. Instead of establishing a vertical program looking at one disease or health condition only, the program integrates several interventions horizontally by simple and effective methods. This approach allows for inclusion of oral health with other health-promoting actions. Despite the pandemic character of child dental decay worldwide, caries prevention is often not among the priorities of health planners. Embedding oral health with other health actions may be the key to effecting behavioral change.
The Way Forward
The FFSP in the Philippines has demonstrated that a school program can be very effective for a range of simple and realistic interventions that address the major health problems of children. With its simple and pragmatic approach supported by a comprehensive policy framework, the experiment in the Philippines may serve as a global model. Oral health programs can play leadership roles in changing communities. The Shils Award will help provide more attention to an integrated comprehensive approach to school health, both nationally and internationally. After all, being fit for school-with clean hands, strong teeth, and healthy bodies-means obtaining a better start in life for a brighter future.
1. Grantham-McGregor S, Cheung YB, Cueto S, et al; International Child Development Steering Group. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369(9555):60-70.
2. World Health Organization. An update of the global burden of disease in 2004. Geneva, Switzerland; 2008.
3. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361(9376):2226-2234.
4. Lear JG. Health at school: a hidden health care system emerges from the shadows. Health Aff (Millwood). 2007;26(2):409-419.
5. Monse B, Benzian H, Panse R. Fit for School. Development and Cooperation. 2008;49:434-435.
6. Monse B, Naliponguit E, Belizario V, et al. Essential health care package for children-the 'Fit for School' program in the Philippines. Int Dent J. 2010;60(2):1-9.
7. Monse B, Benzian H. The Philippines' Fit for School Program. In: Bundy D, ed. Health, Equity, and Education for All: How School Health and School Feeding Programs Are Leveling the Playing Field (Document Prepared for the School Health and Nutrition Theme of the Education for All [EFA] High Level Group Meeting in Addis Ababa, Ethiopia, February 2010). Washington DC: The World Bank; 2010: 75-77.
About the Author
Habib Benzian, DDS, PhD, MScDPH
Fit for School Program
The Health Bureau
Winslow, United Kingdom