School Health Program: Assessment of School-Based Health Services in Schools in Post-Conflict Northern Uganda

Technical Summary: Assessment of School-Based Health Services in Post-Conflict Northern Uganda

Problem Statement
Uganda possesses a young demographic, with over 50% of its population under the age of 17, the majority of whom are school-going children. These children spend approximately 75% of their time in school, a setting that, due to overcrowding and aggregation, acts as a hotspot for the transmission of communicable diseases. While Uganda established a School Health Program (SHP) policy guideline in 2008 to address disease prevention, early treatment, and emergency intervention, the current status of School-Based Health Services (SHBS) remains largely unknown, particularly in Northern Uganda. This region, characterized as post-conflict and the poorest in the country, suffered significant infrastructure and staffing breakdowns during decades of insurgency. Consequently, schools in this region often lack the basic teaching staff, let alone specialized health personnel, raising concerns about the implementation of national health policies and the overall health equity of students in Gulu City.

Methodology
The study employed a cross-sectional survey design to assess SHBS in Gulu City, Northern Uganda.

• Sampling: From a known finite population of 172 schools in Gulu City, a sample size of 121 was calculated using Yamane's formula with a 5% margin of error. An additional 5% was added to account for non-response, resulting in the assessment of 130 schools.
• Selection: The study utilized a systematic sampling method (ratio of 2:1) within the Acholi sub-region cluster, specifically targeting Gulu City due to its high concentration of schools.
• Data Collection: Data was gathered through direct facility inspections and structured interviews with school leadership (headteachers) and health personnel. A pre-tested checklist, adapted from previous studies in Nigeria and modified according to WHO assessments and Uganda's school health policy, was used to evaluate demographics, policies, personnel, equipment, infrastructure, and specific health services.
• Analysis: Quantitative data was analyzed using IBM SPSS Statistics 21, employing frequency distributions, cross-tabulations, and Chi-square tests to determine significant relationships between school characteristics (level and proprietorship) and the availability of health services. Qualitative data from interviews regarding challenges were reported descriptively.

Key Contributions and Results
The study assessed 130 schools, representing 75.5% of the city's total, with a student population of 63,844. The sample was predominantly primary schools (83.8%), mixed-sex (96.2%), day schools (73.8%), and private institutions (71.5%).

• Infrastructure and Personnel:

  • Only 32.3% of schools possessed a dedicated sickbay. Presence was significantly higher in boarding schools (61.8%), secondary schools (61.9%), and public schools (45.9%).
  • Only 26.2% of schools employed a dedicated school nurse.
  • 30.8% had a school counselor.
  • While 60% of schools had personnel trained in first aid, no school possessed an ambulance, and only one had an Automated External Defibrillator (AED).
  • Medical records were available in only 33.1% of schools.

• Policy Implementation:

  • Policy adherence was low: only 6 schools had the school health policy document present.
  • Policies on pre-entry medical check-ups existed in 42.3% of schools, and policies regarding special needs students were present in only 14.5%.
  • However, health and hygiene inspection policies were present in the majority of schools.

• Service Delivery:

  • Screening capabilities were limited: 29.2% could screen for infections, 21.5% for STIs, and 31.5% could assess basic clinical vitals.
  • Specialized screenings were rare: vision (3.8%), hearing (3.1%), nutritional assessment (20%), and special needs evaluation (10.8%).
  • Conversely, 56.9% of schools had essential medicines, and 75.4% maintained contact details for nearest health facilities.

• Statistical Relationships:

  • Secondary vs. Primary: Secondary schools were significantly more likely to have sickbays, health personnel, sports tutors, pre-entry medical policies, and infectious disease screening capabilities compared to primary schools.
  • Public vs. Private: Contrary to findings in some other regions, public schools in this study were significantly more associated with the presence of sickbays, first-aid trained personnel, and regular hygiene inspections than private schools.

• Challenges:

  • The primary challenges cited were the lack of school health workers (69.2%), financial constraints (50.0%), and lack of parental compliance (42.3%).
  • Notably, only one school admitted to a lack of commitment from school administration as a barrier.

Significance and Claims
The paper concludes that there is a widespread lack of functional School-Based Health Services in Gulu City, characterized by deficits in infrastructure, policy awareness, and dedicated personnel. The authors claim that these gaps stem primarily from financial constraints, a lack of awareness regarding the national school health policy, and insufficient enforcement of existing guidelines.

The study highlights that while Uganda has a policy framework since 2008, it has not translated into practice, particularly in primary and private schools. The authors argue that the disparity between public and private schools in service provision suggests that private institutions may be prioritizing cost-cutting over health infrastructure, while public schools benefit from government enforcement and premises.

Implications
The paper asserts that improving SHBS requires:

1. Dissemination and Engagement: Active engagement of schools and stakeholders to clarify and distribute national policies.
2. Supervision: Regular joint supervision by district education and health officials to ensure policy compliance.
3. Prioritization: School management must prioritize health services, potentially involving parents in funding discussions to overcome financial barriers.
4. Equity: Specific attention is needed to ensure primary and private schools are not left behind in health service provision.

The authors maintain a modest stance, noting that their findings are specific to Gulu City but likely reflective of broader trends in Northern Uganda and similar post-conflict settings in Africa. They recommend further assessments of rural schools and the perspectives of other stakeholders (parents, district officials) to fully understand barriers and develop sustainable solutions.