Improved school-baseddeworming coveragethrough intersectoralcoordination:The Kenyaexperience

Improved school-based deworming coverage through intersectoral coordination:The Kenyaexpereince

Kenya

WHO/AFRO Library Cataloguing – in – Publication

Improved school-based deworming coverage through intersectoral coordination: the Kenya experience

1. Helminths – prevention and control – therapy2. Intestinal diseases, parasitic – prevention and control – therapy3. School health services4. Health resources – supply and distribution – utilization5. Organizational Case Studies6. Public-Private Sector Partnerships

I. WorldHealthOrganization.RegionalOfficeforAfrica

ISBN:978-929023260-5(NLMClassification:WC 800)

©WHORegionalOfficeforAfrica,2013

Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the UniversalCopyrightConvention.Allrightsreserved.CopiesofthispublicationmaybeobtainedfromtheLibrary,WHORegionalOfficeforAfrica,P.O.Box6,Brazzaville,RepublicofCongo(Tel:+4724139100;Fax:+4724139507;E-mail:afrobooks@afro.who.int). Requests for permission to reproduce or translate this publication, whether for sale or for non-commercial distribution, should be sent to the same address.

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Disclaimer:Thisreportcontainsthecollectiveviewsofthedraftingteamanddoesnotnecessarilyrepresentthedecisionsorthestated policy of the World Health Organization.

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Contents

Acknowledgments ............................................................................................................ iv

Abstract ............................................................................................................................. v

1. Introduction .................................................................................................................1

2. Background ................................................................................................................1

3. Hypothesis ..................................................................................................................3

4. Methodology ...............................................................................................................4

5. Implementation ...........................................................................................................8

6. Results ........................................................................................................................9

7. Analysis .....................................................................................................................10

8. Conclusion ................................................................................................................11

9. References ................................................................................................................12

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Acknowledgments

ThiscasestudywaspreparedjointlybytheMinistryofHealthandtheSocialDeterminantsofHealthUnit,WorldHealthOrganization,RegionalOfficeforAfrica.Financialsupportwas made available through the Spanish Core Contribution Grant for Social Determinants of Health (SDH)receivedbytheDepartmentofEthicsandSocialDeterminantsofHealthoftheWorldHealthOrganization.TheoverallaimofSpanishCoreContributionGrantforSDH is to strengthen leadership and stewardship role of Ministry of Health to addressing social and economic determinants of health. It supports documentation of country level experiencesinusingintersectoralactionsaimedataddressingthekeysocialdeterminantsof priority public health conditions.

Anearlierdraftofthiscasestudywasincludedinaspecialcollectionofglobalexperienceson intersectoral actions which was widely disseminated during the World Conference onSocialDeterminantsofHealthheldinRiodeJaneiro,Brazil in2011.Atthecountrylevel, the reviewprocess leading to thefinalizationof thecasestudygeneratedmulti-stakeholderpolicyandstrategydiscussionson implementing intersectoralactions toaddress social determinants of health.

Thefinalproduct isaresultofcollectiveeffortsofmanyindividualsandorganizations.However,thedraftingteamincludedDrStewardKabaka,MinistryofPublicHealthandSanitation (Kenya); Dr Christine Kisia, WHO (Kenya); and Dr Eshetu Bekele Worku,UniversityofCapeTown,SouthAfrica. TheoverallguidanceandtechnicalinputstotheprojectfromWHORegionalOfficeforAfricaaregratefullyacknowledged,namely:DrTigestKetsela,DirectorHealthPromotionCluster; Dr Davison Munodawafa, Programme Area Coordinator, Determinants andRiskFactors;DrChandralallSookramandMrPeterPhori;andDrEugenioVillar,SDHCoordinator in WHO HQ, Geneva. We are indebted to the many people who madevaluable inputs throughout the process who cannot be mentioned by name. Last but notleast,weexpressgreatappreciationforthesupportreceivedfromtheGovernmentthrough the Ministry of Health to conduct this activity.

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Abstract

Anationalfaecalexaminationof27729schoolchildrenfrom395schoolscarriedoutin2008indicatedthatintestinalparasiticwormsaffectedanestimatedfivemillion(56.8%)childreninKenya.Existingevidenceshowsthatworminfectionsleadtoreducedliteracylevelsduetoimpairedgrowthandphysicalfitness.

Existingevidencealsoshowsthatimprovedhealthstatusleadstoincreasedproductivity,educational performance, life expectancy, savings and investments, and decreased debts and expenditure on health care. Studies in the United States have shown that worm infections lower literacy levels by 13% and lower earnings later in life by 43%.Research in western Kenya showed that school-based mass deworming (SBD) reduced schoolabsenteeismby25%.

TheSchoolHealth andNutrition Programmeof theMinistry of Education (MOE) andthe Ministry of Public Health and Sanitation (MOPHS) launched a nationwide school-based deworming programme targeting all 22 000 public primary schools in the country in2009.TheKenyaMedicalResearch Institute (KEMRI)undertookextensivemappingsurveys,usingGeographicInformationSystem(GIS)andestablishedwormprevalencelevels in 135 districts with a high population density appropriate for mass treatment. WHO recommends mass deworming in areas where the prevalence of worm infection soil-transmittedhelminthes(STH)isabove50%.

This report outlines the coordination and partnership between two key ministries(EducationandPublicHealth) inKenya,other lineministries,theprivatesector,NGOsand the community in implementing the first phase of a sub-national school-baseddeworming exercise. The areas targeted included Coast, Central, Western, NyanzaandpartsofEasternprovinces,coveringover45districts in thisfirstphase.TheSBDprogrammeisguidedbytheNationalSchoolHealthPolicyandGuidelineslaunchedin2009.

Two crucial national committees coordinate the SBD: the School Health Inter-agencyCoordinating Committee (SH-ICC) responsible for social and resource mobilization andcoordinationandtheNationalSchoolHealthTechnicalCommittee(NSHTC),whichcoordinatestechnicalaspectsofschoolhealthactivities.TheplanningandimplementationofSBDatthedistrictlevelwasdonethroughthedistrictmultisectoralcommittees.ThecommitteemembershipincludegovernmentlineministriesofEducation,PublicHealthandSanitation,MedicalServices,Waterand Irrigation,LocalGovernmentand InternalSecurity.DevelopmentandUNpartnersincludedWHO,theWorldBank,DFID,UNICEF,GTZ, JICA, AMREF and USAID among others. The schoolmanagement committees(SMC) include parents, teachers, pupils and community representatives.

Training for the teachers was done through the National Master Trainers (MT). Theteachers were responsible for administering the deworming tablets and providing health education to parents and pupils in their respective schools. Over 1000 districts, division-level personnel and 16 000 teachers were trained on deworming activities at the end of this phase. Most importantly, 3.5 million children from 8000 schools were dewormed. Theprogrammerecordedahugesuccess(70%)intermsofscopeandwasextremely

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cost-effective.ThedewormingprogrammehadanoverallcostofapproximatelyUS$0.3per child per year.

This exercise also resulted in the introduction and integration of other school healthprogrammes such aswater, sanitation and hygiene, values and life skills and schoolmeals, which were implemented through the same existing structures that complement the deworming programme. This has also ensured sustainability of the dewormingprogramme.

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1. Introduction

Accordingtothe2008nationalcensus,thetotalnumberofschool-agechildreninKenyawasestimatedat10624380with9108952(82%)athighriskofintestinalparasiticwormsinfections.Agrowingbodyofresearchidentifiesstronglinksbetweenchildren’shealthand social and educational outcomes. Additional evidence also notes the reciprocalbenefitsofaccesstoqualityeducationontheindividualandfamilyhealthstatus.StudiesintheUnitedStateshaveshownthatworminfectionslowerliteracylevelsby13%andlower earnings later in life by 43%.Research inwesternKenya showed that school‐basedmassdewormingreducesschoolabsenteeismby25%.Anationalmassfaecalsurveycarriedoutin2008estimatedthatfivemillion(56.8%)schoolgoingchildrenwereactually infected with intestinal parasitic worms and required mass deworming as per WHOguidelines(S.Brooker,2008).

Evidence has shown that improved health status leads to increased productivity,educational performance, life expectancy, savings and investments, and decreased debts andexpenditureonhealth care. Inaddition, theoverall improvementof the student’sclassattendanceisexpectedtopositivelyaffecthealthoutcomes,specificallyinareasof child and maternal health. Studies conducted in the country have shown a strong relationship between the education level of girls and subsequent child and maternal mortality reduction;withhigher(primary level)education levelsbeingdirectly linkedtobetter outcomes in child and maternal health.

Inordertoaddressthesetwokeydeterminantsofhealth,theMinistryofEducation(MOE),in partnership with the Ministry of Public Health and Sanitation (MOPHS), launched a nationwide School-Based Deworming Programme implemented in three phases, targeting 22 000 public primary schools.

Figure 1: Summary of key statistics, Kenya

Related DataTotalpopulation 40,863,000Primary School (age) population 10,624,380School going children 8,661,333Children out of school 1,963,047PopulationatriskofSTH 9,108,952No. of Public primary schools 22,000

2. Background

TheKenyaGovernmenthasdevelopedvariouspoliciesandprogrammesforsocialandeconomic development. Many of these policies and programmes have been implemented which have achieved good results and made an impact, while some have ended up at the policy level with limited implementation. Implementation of policies requires intersectoral collaboration, both at national and international levels, on the agreed health goals, including theMillenniumDevelopmentGoals (MDGs).There isanurgentneed

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fortheKenyaGovernmentanditsdevelopmentpartnerstorenewtheircommitmenttothese goals by reinvigorating efforts and by strengthening the strong interrelationship among health determinants and social and economic development such as governance, education, gender and culture, food security and nutrition, environment, peace and security.

Kenyahasayoungpopulation,withtheyouthmakingupabout48%ofthetotalpopulation(nationalcensus2008).The levelsofpoverty in thecountryarequitehigh; theUNDPHuman Development Report (2004)estimatedthat54%ofthetotalpopulationwaslivingin absolute poverty. Literacy rates, education levels and policy actions are still related to the geographical missionary and colonial settlements, which favoured the more fertile highlandsanddistrictscomparedtootherpartsofthecountry.Thenationalliteracyratestandsat80%;however,thelevelsofeducationarevariedacrossthecountrywithsomeareashavinglowerratesduetolimitedaccesstoeducationalfacilities.Only40%oftheruralpopulationhasaccesstopipedwater.Morethan50%ofthepopulationdoesnothaveaccesstomodernhealthfacilitiesand40%hasnoaccesstosafedrinkingwaterand sanitation.

Thehealthgapswithinthecountryhavewidenedduetoinequitabledistributionofresourcesand lack of provision of new technology to address the newand re-emerging healthproblems (Von-Shrinking, 2002). Kenya’s health systemsareweak and inappropriate,they are replicas of what was inherited from the colonial era and are therefore unevenly weighted towards privileged elites and urban centres. Health facilities, services and an overwhelmingmajorityofhealthworkersareconcentratedinurbanareas.

The average annual expenditure on the health sector is 7% of theGDP. Health carefinancing depends heavily (52%) on out-of-pocket payments for services or financialassistance frombilateralandmultilateraldonors.TheCoastprovince,partsofCentralandEasternprovincesand theLakebasin (WesternandNyanza)provinceshave thelowest socioeconomic status, which exposes the population to high soil-transmitted helminthes (STH) infections. The Kenyan health system also faces human resourcescarcity.Allcategories,particularlydoctorsandnurses,are inshortsupplycomparedto the standards of population. Human resource crisis in the health sector, caused by inadequate production in the country, inability to hire others, brain drain, poor motivation,conflictofinterest,corruptionandmisuseofresources,hasunderminedtheimplementation of decentralized public health services.

Kenya faces numerous challenges in preventing and controlling communicable and parasitic health conditions which are mostly water-borne, resulting from poor sanitary andhygienicconditions.STHinfectionsoccuralmost inall impoverishedcommunitiesof humid tropics and are found commonly in school-age children (Stephenson, 1994).Theglobal diseaseburden of these infections quantifiedby index, disability-adjustedlive years (DALYs), ranked first in 5-14 years age group for bothmales and females(World Bank, 1993). Consequences associated with these infections include impaired growthandphysicalfitness,impairedinformationprocessing,reducedretrievaloflongmemory and immediate recall and low overall cognitive ability (Nokes et al., 1993, Bovin et al., 1993).ThemajorityoftheKenyanpopulation(90%)isdistributedinruralareas,primarilyinthreeclusters:theLakeVictoriabasin,partofCentralandEasternProvinces,

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andalongtheIndianOceanontheCoastalbelt.TheCoastalbeltofKenyaandtheLakeVictoriabasinhavehighhumiditymoisturessuitableforSTHsurvivalandgrowth.

An extensive mapping survey carried out by the Kenya Medical Research Institute(KEMRI)usingtheGeographicInformationSystem(GIS)toestablishwormprevalencelevelsinthecountrywasusedtoidentifydistrictsappropriateformassdeworming.TheareasmappedincludedtheCoastandpartsofEastern,Central,WesternandNyanzaProvinces. 135 districts with a high population density and prevalence of worm infections (above50%)thatwereidentifiedformassdewormingtreatment.

ThereisaclearevidencethatsuggeststhatlowlevelsofgeneraleducationandhealtheducationaredirectlyproportionaltothedegreeofSTHinfection,soislowsocioeconomicstatus of families of these children (Kan, 1992). Consequently, mass deworming was selectedasanimportantcost-effectiveandcost-benefitactivitybecauseintestinalwormsdamagechildren’shealth,discriminatethelevelsofschoolperformance,loweracademicachievement, hinder access to education and reduce social competence and regular school attendance.

3. Hypothesis

According to the national mass faecal examination survey (2008), intestinal parasiticwormsaffectanestimatedfivemillion(56.8%)childreninKenya.School-goingchildrenaged13-14yearsexhibitedthehighestprevalenceofSTHinfection(70%).ThroughthehelpoftheGIS,135geographicaltargetsthatcouldbenefitfrommassdewormingwereidentified. According to WHO guidelines, mass deworming should be undertaken inareaswhere theprevalenceofworm infection isabove50%. GiventhemagnitudeoftheprobleminKenyaandtheneedtocontroltheburdenofSTHinfection,adecisiontodeworm schoolchildren was agreed upon as the best possible solution.

Theschool-baseddeworming(SBD)programmewasexpectedtocontributetotheoverallgoal of the comprehensive school health programme which aims to achieve healthy childreninaconduciveenvironmentforteachingandlearning.Thereareseveralreasonsfor the selection of the mass deworming exercise through the school health programme. First,school-agechildrensufferthehighestintensityofworminfections;thiswasbasedontheresultsofthesituationanalysisandGISmapping.Secondly,easyaccesstothetarget population as schools are natural places to access a large number of children. Thirdly,theprogrammeiscost-effectiveasitwoulduseexistinginfrastructure,especiallyteachers trained to administer deworming tablets to their pupils.

Since2003,thecountryhastakendeliberatestepstoimprovetheeducationstandardsinthecountry.Thisisduetotherecognitionofeducationasoneofthedrivingforcesofacountry’seconomyandsocialprogressandalsoasoneofthemajordeterminantsofhealth.Theintroductionoffreeprimaryeducationin2008inthecountryprovidedagoodentrypointfortheschoolhealthprogramme.Therewasasupportivepoliticalgoodwillenvironment from the government and a conducive environment for collaboration among various government sectors and partners, hence the acceptance of the national school health (NSH) programme by many stakeholders. The development of the nationalschool health policy and guideline documents has also been instrumental in guiding all

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stakeholders implementing theschoolhealthprogramme.Finally, theexistingpoliticalwill at that time was supportive to have the programme implemented and use deworming as an entry point to other school health programmes, e.g. water, sanitation and hygiene.

TheoverallimpactoftheSBDprogrammeoneducation,includingimprovementofliteracyrates,reductionofschoolabseentismanddropout,willbeanalysedinduecourse.Thisis due to the long-term nature of the expected impact indicators.

4. Methodology

The school-based dewormimg programme was implemented under the umbrella oftheNationalComprehensiveSchoolHealth (NCSH)programme.TheNationalSchoolHealthPolicyandGuidelinesweresuccessfullylaunchednationallyin2009.Thepolicydocument was to provide clear directions on the implementation of the eight thematic areas,whichare:valuesandlifeskills;genderissues;childrights,childprotectionandresponsibilits;water sanitationandhygiene;nutrition;diseasepreventionandcontrol;specialneeds,disabilityandrehabilitation;andschoolinfrastructureandenvironmentalsafety. The organizational structure for implementation is clearly spelt out in theseguideline documents.

Figure 2: National school health policy and guidelines documents, Kenya

The Ministries of Education and Public Health and Sanitation, through two nationalintersectoral committees, jointly coordinated the programme. These are the NationalSchool Health Inter-Agency Coordinating Committee (SHN-ICC) responsible for thecoordination, resource mobilization and advocacy of the comprehensive school health programme. Theother committee is theNationalSchoolHealth TechnicalCommittee(SHN-TC)responsibleforprovidingtechnicaladvicetotheSHN-ICC.

Various government sectors and development partners, through the two nationalcommittees,contributedmostoftheresourcesforthesuccessoftheprogramme.TheMinistriesofEducationandPublicHealthandSanitationplayedtheroleofcoordinator.

The Ministries of Water and Irrigation and Local Government provided safe drinkingwaterandlogisticalsupporttotheschools.InternalSecurityandAdministrationprovidedsecurity,especiallyinsomeofthehard-to-reachandinsecureareas.TheMedicalServicesministry provided the deworming drugs, while the Ministry of Public Health and Sanitation

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provided the health staff for training resource persons. TheKenyaMedical ResearchInstitute(KEMRI)providedevidence-basedinformationthroughresearchtosupporttheprogramme.Theyalsoprovidedcrucial informationbymonitoring the trendsofworminfections in the country.

Thecommunitygavetheconsentforthechildrentobedewormed,providedsafewaterfor administering the drugs and supported the children physically by accompanying them toschool.With thesupportof IPAandothercommunity-basedNGOs, thecommunityformed groups to inform and educate other members on the health messages they were receiving.Themessagesemphasizedtheimportanceofdewormingandwerepassedon through various channels including mass media, print media, parents-teachers association forums and local radio stations.

WHO provided technical support, especially in the planning, monitoring and evaluation of theprogramme;theWorldBank,DFIDandUNICEFprovidedfinancialsupport,whichwasveryessentialforthesuccessoftheactivity.The‘DewormtheWorld’providedtechnicalassistance, funding support and secured and managed the donation of deworming pillsfromtheFeedtheChildren.TheKEMRI-WelcomeTrustprovidedcrucialscientificinformationandsupport.ThePartnershipforChildDevelopment(PCD)supportedthedevelopment of trainingmaterials and themaster training sessions. The Innovationsfor Poverty Action provided logistical support for the roll-out and for the analysis ofprogramme data.

The Japan International Cooperation Agency (JICA) has been a long-term partner ofschool health in Kenya and has supported deworming efforts for many years. Thisprogramme is truly an example of successful cooperation and partnership among a wide rangeofgovernmentandnongovernmentalstakeholders.

The school-baseddewormingprogrammewasmanaged through various interrelatedsub-committees, namely:

• Trainingandmaterialdevelopment• Drugdistribution• Monitoringandevaluation• AdvocacyandIECmaterialdevelopment.

Atthedistrictlevel,theDistrictMedicalOfficerofHealth,DistrictClinicalOfficer,DistrictPublicHealthOfficer,DistrictNutritionOfficer,DistrictEducationOfficerandtwoqualityassuranceEducationOfficersreceivedthetraining.Thedistrict-trainedteamscascadedthetrainingtothedivisionalteamswhichincludeddivisionalpublichealthofficers,clinicalofficers inchargeofhealth facilities,nurses inchargeofdispensaries,areaeducationofficersandTACtutors.Thetraineddivisional teamsfinally trainedtheheadteachers,school health teachers, parents, pupils and community in a cascaded pattern. Alsoinvolved in the planning and implementation of the programme were parents, pupils and the community through existing parents-teachers association and community structures. Thetrainingofteacherswentalongwayindemystifyinganymisconceptionsorrumouredmyths in the communities resulting in very high acceptance rates. Community leaders played a pivotal role of advocating for the deworming activity at all levels of society.

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Figure 3: A depiction of the training cascade

Wewillnowtalkbrieflyabouttheplanningandlogisticsbehindthedewormingroll-out.First,thetrainingactionplanwasdesignedandscheduledwithtimelines.Thetrainingmaterials had been previously designed and adopted by the Ministries of Public Health and Sanitation and Education and partners. Organizing thematerials and sorting bydistrict was quite a tedious process, but proper advance planning ensured that the roll-out went smoothly and each district received enough materials for the training programme. Thepicturesbelowshowsomeofthetrainingmaterialsusedintheprogramme.

Figure 4: Training materials produced for the school-based deworming programme in Kenya

Training materials

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Thepreparatoryactivitiesinvolvedthetrainingofthemastertrainers,thecoreteamthatrolledouttheprogramme.Thirtymastertrainerswereselected,onethirdeachfromtheMinistryofEducation,theMinistryofPublicHealthandSanitation,andfromKEMRI.Thetrainingof30national-levelmastertrainersondewormingwasdoneinMay2009.TheMinistryofPublicHealthandSanitation,KEMRIwithsupportfromtheDewormtheWorldInitiativeandPCDcoordinatedthetrainingsession.Trainingofthedistrictanddivisionalteams and the school community followed thereafter. Community mobilization activities to inform and educate the community were carried out in various social functions and gatheringssuchaschurches,mosques,chiefs’meetings,etc.).Anationaldewormingtraining manual had initially been developed by the Ministry of Public Health and Sanitation. Thiswas ratified andadaptedby theNational SchoolHealth TechnicalCommittee toguide the entire process.

All trainingmaterialswereorganized intopre-sortedboxeswithappropriatequantitiesforeachdistrict.Thenumberof trainees fromeachdistrictdetermined thequantityoftraining materials required for each district. On the other hand, the estimated number of children targeted for deworming from each district determined the number of doses ofdewormersforeverydistrict.Finally,all logisticsrelatingtopersonnel,transportandtrainings were planned according to the size of the district and the distance from Nairobi, the central coordinating point. Other preparations included the prepositioning of the drug supplies (mebendazole and albendazole) and establishment of transportation and communication logistics mechanisms in each district. 116 million doses of mebendazole 500mgwereusedduringthisfirstphase.

The drug distribution protocol for the national school health deworming programmeinvolvedfivemajorsteps:

Step One: National level to provinces

The drugs were transported from the national storage depot of the Kenya MedicalSuppliesAgency(KEMSA)totheregionalmedicaldepotsinNyanza(Kisumu),RiftValley(Eldoret),Western(Kakamega)andCoast(Mombasa)provinces.

Step Two: Movement of drugs from provinces to targeted districts

The next phase of distribution involved the distribution of drugs from the provincialheadquarterstothedistricts.Thedrugquantityestimatesforeachdistrictweredonebythegovernment(MinistryofHealthandMinistryofEducation)andbytheInnovationforPovertyAction(IPA),anNGO,whichisactivelyinvolvedinthedewormingprogramme.

Step Three: District to division (teacher training sessions)

The peripheral health facilities in-charges would order the drugs from the districtheadquarter in accordance with the number of targeted children to be dewormed in their specifiedcatchmentareas.Thefacilityin-charges/divisionalpublichealthofficerswouldoversee the redistributionof thedrugs to theirspecifiedschools.The teacher trainingsessions happened concurrently with the drug distribution to schools.

Step Four: Division to schools (teacher training sessions)

Thedivisionalpublichealthofficers(DivisionalPHOs)overseetheonwarddistributionof

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drugstotheschoolhealthteachers/headteachers.Theschoolheadteacheroverseesthe actual deworming process and the necessary documentation for its monitoring and evaluation.

Step Five: Reverse cascade - schools back to division to district

Any unused drugs are brought back through the reverse cascade. The school headteacher/healthteacher/areaeducationofficerensuredsubmissionoftheunuseddrugstogetherwiththemonitoringformsbacktothedivisionalPHOs/facility in-charges.ThegovernmentofKenyaand the Innovation forPovertyAction(IPA) jointlysupported thewhole cascade programme of the drug distribution. Before the actual implementation of activities, the recording, reporting and monitoring tools were also developed.

Figure 5: School health coordination structure, school-based deworming programme, Kenya

5. Implementation

TheNationalDewormingProgrammewaslaunchedonApril22,2009atacolourfuleventpresidedoverbybothMinisterofEducationandMinisterofPublicHealthandSanitationandattendedbyHonourableMinisters,AssistantMinistersandPermanentSecretariesofbothministries.Theparticipantsmadespeechesdemonstratingtheirstrongandfirmsupport of the deworming programme. TheactualdewormingcommencedinJune2009whilethedataanalysiswasdoneatthenationallevelanddisseminationofthereporttovariousstakeholderswasaccomplishedinAugust2009.

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6. Results

ThenationalprogrammeinPhaseOnetargeted45districtsand8000schoolsthatwereallsuccessfullyreached.Atotalof16000teachersand1000district-anddivision-levelpersonnelweresuccessfullytrainedonthedewormingprocess.Theteacherssupportedthe deworming process in the 8000 schools. Most importantly, 3.5 million children directly benefitedfromtheprogrammeandweredewormed.Thismeant70%successrateoutofthefivemillionchildrentargetedforphaseddeworming.

Minister for Education, Hon. Professor Sam Ongeris, and the Minister for Public Health and Sanitation, Hon. Beth Mugo, launching the school health documents in 2009.

A school teacher delivering the deworming tablets to the children during the first phase of the programme in Kenya.

Not only was the programme a huge success in terms of scope, it was also extremely cost-effective.ThecosttotheGovernmentofKenyawasapproximatelyUS$0.24per

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childper year. ThiswassupplementedbyapproximatelyUS$0.06perchildper yearfromdevelopmentpartners.Therefore,thedewormingprogrammehadanoverallcostofapproximatelyUS$0.3perchildperyear.Thisincludesallprogrammecosts:socialmobilization, training, logistics, deworming drugs, monitoring, printed materials, etc.

The school-based deworming cascading programme has established coordinationmechanisms that have enhanced coordination structures for implementation of other comprehensiveschoolhealthpackagesintheinitiallytargetedregions(Coast,Nyanza,Western and Rift Valley Provinces). The programme also raised awareness andgovernment commitment in supporting it in other initially non-targeted regions, e.g. Nairobi.TheincreasedadvocacyhasalsoledtothefundingofthesecondphaseoftheprogrammeforaperiodoffiveyearsuptoUS$14million.

Schoolchildren receiving deworming tablets during the first phase of the programme in Kenya.

7. Analysis

The use of the existing government structures that include the national coordinatingcommittees and the school infrastructures greatly helped and led to the success of the programme and greater involvement of other partners. The joint leadership andcoordinationoftheprogrammebythetwoministries(HealthandEducation)promotedinvolvementofotherlineministries,developmentpartners,UNagencies,NGOsandtheentire community.

The response to theprogramme through thecommunity sensitization initiativesusingvariouschannelswasgoodinthefirstphase.Thiswasevidencedbythecommendablesuccess achieved by reaching 70% of the targeted children and creating increasedawarenessonthebenefitsofdewormingofschoolchildren.

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Theimplementationprocesswassuccessfulinachievingtheintendedtargets,includingthe training of all targeted teachers and government personnel, cascading of information and supplies from the national level to the schools, and increased partner involvement and participation in the programme.

Accordingtoexistingevidence,school-baseddewormingprogrammesinothercountriescostanaverageofUS$0.4perchildperyear,whiletheoverallcostinKenyaforthefirstphaseoftheprogrammewasUS$0.3perchildperyear.Thelowcostcouldbeattributedto the intensive partnerships in sharing various roles and responsibilities, use of existing coordination structures and infrastructures as well as strong community involvement and ownership.

8. Conclusion

Atotalof3.5millionschool-goingchildren(70%ofthetarget)weresuccessfullydewormedin the45districts targeted for thefirstphaseof thedewormingprogramme.Thiswasmade possible through effective leadership and coordination of the roles of various governmentagenciesandstakeholders, useof existing structuresand infrastructuresand active involvement of school teachers and community, supported by an intensive social mobilization initiative. The establishment of clear coordinationmechanismsby bothMinistries of Educationand Public Health and Sanitation enabled the harmonization of activities of other sectors, including other government line ministries, donors, private organizations, community, teachersandstudents.Thisintersectoralactionwasnotonlysuccessfulinreachingitstargetpopulationbutitprovedtobequiteefficient,costinglessthantheaveragecostofdewormingachild.Theprogrammealsoprovidedfortheintroductionandintegrationofother components of the school health programme through established mechanisms.

School children utilize water tanks and facilities established for deworming for hand washing

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One of the strong recommendations from the first phase is the need for monitoringandevaluationoftheprogramme’soutcomeindicators.Theseincludereducedschoolabsenteeism and drop-out rates, increased intelligence and academic performance, increasedwageearningsanddecreasedhealthcareexpenditure.Arandomizedcontroltrial experimental research to compare the impact in the 45 districts that received the interventionvis-à-visthedistrictsthatdidnotreceiveitinthefirstphaseisrecommended.

9. References

MichaelKremerandEdwardMiguel:PovertyActionLabPaperNo.6,September2001.

Nokes C. Bundy D. Compliance and absenteeism in schoolchildren: implications forhelminthescontrol.TransactionsoftheRoyalSocietyofTropicalMedicineandHygiene1993, 87:148 – 15-21.

MiguelE.RKremerM.(2002).Worms:Identifyingimpactsonhealthandeducationinthepresence of treatment externalities.

KenyaNationalCensus2008:MinistryofNationalPlanningandVision,2030.

978- 929023260- 5

ISBN 978-929023260-5