By Hamis Mugendawala
As we all aspire to transform Uganda into a modern and prosperous society with an annual income of $9500 by 2040, Universal Health Coverage (UHC) is one of the strategies to deliver us to this promise. This strategy is aligned to Sustainable Development Goals (SDG) 3 target 8. To attain UHC, interventions should be towards having more than 90% of all Ugandans accessing quality health services without financial constraints.
The findings of National Planning Authority (NPA) contained in its 2018 paper; ‘ Towards Universal Health Coverage in Uganda; Multi-Sectoral Policy Actions to Accelerate Progress’ show a pessimistic outlook in terms of progress made by Uganda as a country, even in relation to her peers such as Rwanda and Botswana towards UHC. For instance, it is clear that while government funding continues to decrease, the Burden of Disease (BoD) is unrelenting, with 60% of BoD attributable to Communicable Diseases (CDs) and 40% to Non-Communicable diseases (NCDs). Equally worrying is the fact that the health system is currently obsessed with the curative approach to promoting health yet 75% of the BoD is preventable. Actually, our BoD is mainly perpetuated by factors relating to nutrition, sanitation, hygiene, water, accidents and housing, which are within our ambit. It is therefore clear that Uganda’s strategy to achieving UHC lies in preventive health care rather than curative. This is partly informed by the determinants of health in the country and the country’s inability to serve the demand for curative care. And so, it can only be logical to prevent people from falling sick and then concentrate the meager resources on the inevitable curative healthcare.
Governments like the Uganda government should be helped to invest more in preventive than curative health care; it is far less messy and less wasteful
Source of illustration: http://advancedlifestylemedicine.com/?page_id=13
One institution that occupies a vantage position in preventive healthcare is the school (mainly referring to pre-primary and primary school). Of course, this thesis is sort of aloof with the general norm that the hospital and hence the health sector are the only custodians of health. Honestly, we cannot go far with such thinking. Rather, the thinking should be around a multi-sectoral approach requiring various institutions within and beyond the traditional health realm playing in concert to deliver UHC. And indeed the school can play the nexus role in such a multi-sectoral arrangement.
There is irrefutable evidence to suggest that most of our health is made and or impaired in school. This is mainly on the assumption that this is where health and unhealthy behaviors, attitudes, knowledge, and values are propagated. Besides, schools have been used as conduits for key health interventions. Some of such evidence has been adduced from the British Cohort Study 1970 (BCS70), a very popular longitudinal study that follows up the lives of more than 17,000 people born in England, Scotland and Wales in a single week of 1970. From this cohort data, Conti and his team reported in 2010, that immense health endowments of the cohort members were directly linked to early schooling. According to Conti and team, early schooling was found to have significant causal relationships with regular exercise, low rates of drug abuse, reduced obesity, reduced rates of depression and fallen rates of daily smoking. This finding informed one of their conclusions that better early schooling leads to better health in early life which also leads to better health and health-related behaviors later in life and better labour prospects. This, therefore, implies that years of formal schooling, particularly in early life, probably is the most important correlate of good health. A similar view is strongly held by the renowned Dr Mitch Blair who observed that early schooling tends to heavily integrate education, child care, parenting support and health services, which are all critical pillars of especially preventive health care. To reinforce how education (the school) is one of the most important predictors of health, Dr Mitch Blair cites evidence from the USA, demonstrating that if everyone had a comparable standard of schooling (at mean levels), then 1,369,335 lives could be saved in the USA between 1996-2002, compared to only 178,193 lives saved by medical advances over the same time period.
The school’s curriculum and programmes address nutrition, sanitation and hygiene, immunization, water, socio-emotional aspects of learners, and physical exercise. Besides, if schools are capacitated, they always: feed the children on nutritious meals, engage the learners in creative arts and physical education, maintain proper hygiene and sanitation, provide clean water, and in some instances provide appropriate accommodation to the children. If every school implemented all such programmes, would prevent above 9 Million young Ugandans in schools from falling sick. This would be of significant impact towards the achievement of UHC. This is on the backdrop that a lot of resources that would have been allocated to treat such a mass of young persons would be freed for adult and elderly populations’ care. More likely, this would guarantee more health coverage.
On the other hand, it has also been proven that schools can act as nexus that links learners, families, communities and government and rally them around a health cause. In Uganda, it is a growing phenomenon for schools and or their OBs and OGs to organize free health camps to not only sensitize the communities on how to stay healthy but also treat the communities for their common illnesses. We have also witnessed some schools that have the resources offering school-based health care, nutrition education and family planning among others, to the community. Such initiates have the potential to, in the first place, lower the BoD and also complement the curative efforts of government, hence acting as catalysts towards the attainment of UHC.
Courting the school as a strategic partner
In as much as schools are expected to undertake the above programmes which have been proven to offer health benefits, in reality, many of them are incapacitated to do so. Most of the schools lack the funds and human resources to run such programmes. For instance, whereas schools used to be reference centres for good nutrition, good hygiene and sanitation, fewer schools are able to feed the learners as expected and most of the infrastructure for hygiene and sanitation has been rundown and is dilapidated. Further, programmes with significant health benefits such as creative arts and physical education and sports are getting limited attention since most of the schools are obsessed with academic teaching and drilling of children to pass pen and paper examinations. All these are reducing our odds of hitting UHC on time. This therefore implies that we must chart strategies that would turn schools into strategic partners towards attainment of UHC.
It is clear that schools affect the health of the learners and the community through majorly their programmes which are mainly embedded in the curriculum. Therefore, the most logical recommendation should be to require schools to balance academic and non-academic programmes that have a high and positive impact on health. This necessitates a robust school inspection system in place to quality assure such programmes and ensure that they are timetabled and executed as intended.
Further, there is need to capacitate schools in terms of human and financial resources to actively partake in the identified impactful programmes. This is required to establish, maintain and optimally utilize the hygiene, sanitation, school gardening, and physical education and sports infrastructure. Since no ministry may have adequate budgets to single-handedly fund such programmes, the most logical approach would be to break the silo modes of operation in the provision of services such as health and education, to allow strategic institutions such as schools benefit from monies from the various sectors including health, water and environment, energy, education, gender social and labour, to undertake the various cross-cutting programmes that post higher health benefits. Further, we should aim at establishing one-stop delivery centres particularly for Early Childhood Education and development under the multi-sectoral arrangement to offer education services alongside child protection, nutrition, and health care.
The school provides a good environment and setting for healthy growth
It is also critical to facilitate schools to engage more in community outreach programmes, health literacy days, and adult literacy programmes with the overarching objective of promoting health related behaviours for disease prevention. Moreover, such outreach programmes should aim at cultivating, nurturing partnerships between local communities and schools in the promotion of health and wellness. For instance, schools can freely offer playgrounds and halls for communities to have an opportunity to interact and as well undertake physical activities. Such interactions have been found to build trust, establish shared norms that support success, and link residents to health-promoting networks and services.
Whenever appropriate, the government should make the school a routine conduit in the delivery of its health programmes. Given that about 92% of all parishes in Uganda have a government primary school and given that about 9 Million children are in pre-primary and primary schools, guarantees greater reach and penetration of any government health programme delivered through the school. This explains the success of immunization programmes that have been administered through schools. Also, schools are already playing a significant role in preventive health care by making immunization cards and child development cards part of the requirements for enrolment in school. Already, reports indicate that such initiatives have ensured that almost 100% of children in registered schools have been vaccinated against the killer diseases including cervical cancer among the young girls. All this, demonstrates that a school is a gold mine when it comes to promotion of preventive health if carefully targeted and supported.
Lastly, given the irrefutable evidence that education improves lifetime health, it becomes critical for the spheres of influence including the school, parents and government to ensure that all school-age children are enrolled and kept in school. This would guarantee early years’ health to about a third of the country’s total population, thereby freeing up resources towards providing health access for adults and the elderly.
Whereas Uganda has made strides towards UHC as one of the strategies to achieve agenda 2030 and Vision 2040, so much remains to be done within just a decade. Therefore engaging the usual gear can never move us at the speed we require to arrive at UHC on time. This implies that we have to act creatively and perhaps think outside the box. It this article, it has been argued that, given that most of the health problems experienced in Uganda are preventable, preventive health care should be the strategic direction to be pursued. This would allow the concentration of the meager resources on the inevitable curative care. Accordingly, the school has been found to be in a vantage position to provide the direly needed preventive health. Therefore, there is a need to court the school into a strategic partner in the delivery of UHC. This would require a multi-sectoral approach to capacitate the school in terms of human and financial resources to enable it to revamp hygiene, sanitation, school gardening, and physical education and sports programmes that address the critical determinants of UHC.
The writer is Senior Planner in charge of Education at the National Planning Authority