Ethiopia School Health Program Framework 1

Federal Democratic Republic of Ethiopia

Ministry of Health

SCHOOL HEALTH PROGRAM FRAMEWORK

Be Healthy to Learn and Learn to be Healthy

Addis Ababa, Ethiopia

August 2017
Ethiopia School Health Program Framework 1

Forward
The Federal Democratic Republic of Ethiopia, Ministry of Health (MoH) recognizes that a lack of health
and nutrition programs in schools impacts a child’s ability to learn and leads to poor school attendance
and higher dropout rates, increasing education wastage. We also recognize that disease, disability and ill-
health conditions are major impediments to effective learning—limiting the realization of children’s full
productive potential and national development and poverty reduction efforts. This initiative will
strengthening Ethiopian health services to focus on a life-cycle approach as concern shifts away from
mere survival towards improving the quality of life.

The MoH in collaboration with other line sector ministries, in particular the Ministry of Education (MoE),
is responsible for equipping students with the necessary knowledge of health, hygiene and nutrition for
better academic performance and later on increased working potential and productivity. Building on the
National School Health and Nutrition Strategy, whose development was led by the MoE, this document
aims to move beyond nutrition and close the gap on reaching children with health services by providing
comprehensive school health service packages at all levels of schools ranging from the pre-primary to
tertiary level of education.

This school health program (SHP) framework aims to help guide service providers and administrators at
different levels of education to provide quality, standardized and comprehensive promotive, preventive,
curative and rehabilitative health services to school students at the pre-primary, primary, secondary and
tertiary levels of education in a healthy environment. The ten service packages listed here in this
document are organized and contextualized according to the level of school and consider the age and sex
of the students. During the implementation of the SHP, close linkage and collaboration of school health
care centers with the existing health facilities and administrative offices will be ensured.

Prof. Yifru Berhan

Minister of Health
Ethiopia School Health Program Framework 2

Acknowledgements
The Federal Democratic Republic of Ethiopia, Ministry of Health would like to acknowledge the
leadership and commitment of the Government of Ethiopia in supporting the extension of the School
Health Program (SHP) to standardized service packages in schools. The MoH also appreciates the MoE
for initiating the school health and nutrition initiative by developing a related strategy in 2012. The MoH
would like to extend its acknowledgement for the valuable contribution of program managers, technical
staff, experts, stakeholders and partner organizations who actively participated in the preparation and
development of this SHP framework document.
Ethiopia School Health Program Framework 3

Acronyms and abbreviations

AYH Adolescent and Youth Health
BCC Behavior Change Communication
CSA Central Statistics Agency
EMIS Education Management and Information System
EPHI Ethiopian Public Health Institute
EiE Emergency in Education
MNS Mental, Neurological and Substance use
FHAPCO Federal HIV Prevention and Control Office
GBV Gender Based Violence
GTMP Global Trachoma Mapping Project
HBAgs Hepatitis B surface Antigen
HC Health Center
HEP Health Extension Program
HEW Health Extension Workers
Hgb Hemoglobin
HIV Human Immunodeficiency Virus
HMIS Health Management and Information System
HO Health Officer
HPV Human Papilloma Virus
HTP Harmful Traditional Practices
IEC Information, Education and communication
ISHP Integrated SHP
ITNs Insecticide-treated bed nets
IUCD Intrauterine contraceptive device
MDA Mass Drug Administration
MoE Ministry Of Education
MoH Ministry of Health
MOWIE Ministry of Water, Irrigation and Electricity
MHM Menstrual Hygiene Management
MUAC Mid Upper Arm Circumference
NCD Non Communicable Diseases
NGOs Non-Governmental Organization
Ethiopia School Health Program Framework 4

OCP Oral Contraceptive Pills

PHCU Primary Health Care Unit
PTAs Parent–Teacher Association
PID Pelvic Inflammatory Diseases
RDA Recommended Daily Allowance
RPR Rapid Plasma Reagent
RUTF Ready-to-use therapeutic food
SBCC Social and Behavioral Change Communication
SHN School Health and Nutrition
SHP School Health Program
SRH Sexual and Reproductive Health
STI Sexual Transmitted Infections
SLOT Strength Limitation Opportunity and Threat
SDG Sustainable Development goals
SSA Sub Saharan Africa
TB Tuberculosis
Td Tetanus diphtheria
TOT Training of Trainers
TT Tetanus Toxoid
TVET Technical and Vocational Education and Training
UN United Nations
UNESCO United Nations Educational, Scientific and Cultural Organization
URTIs Upper Respiratory Tract Infection
VCT Voluntary Counseling and Testing
Vit A Vitamin A
WASH Water, Sanitation and Hygiene
YD Youth Dialogue
ARF Acute Rheumatic Fever
RHD Rheumatic Heart Disease
GAS Group A Streptococcal
Ethiopia School Health Program Framework 5

Operational definitions
School: An institution (both private and public) designed to provide learning spaces and learning
environments for the teaching of students under the direction of teachers from pre-school to tertiary
level of education
Preschool or pre-primary level education: Preparatory teaching for primary level education
Primary level education: 1-8 grades (1st cycle grades 1-4, second cycle grades 5-8)
Secondary level education: 9-12 grades (High school grades 9-10; Preparatory grades 11-12)
Tertiary level education: TVET, Colleges and Universities
SHP: A program designed with a defined package of health services offered in schools that are designed
to promote students' physical, emotional, and social development, and to prevent and treat health
problems of students
Child: Any person less than 18 years of age
Adolescent: Any person between 10 to 19 years of age
Youth: Any person between 15 to 24 years of age
Young person: Any person between 10 to 24 years of age
Pre-school or pre-primary children: children 4-6 years of age enrolled in KG or any other alternative
pre-school setting
School-age children: Children attending schools at all levels in the country who are age 7 and greater
School Feeding Program: A Social Safety Net instrument that targets children in chronically food
insecure areas and protects them against the worst consequences of household food insecurity and
contributes to better learning and educational outcomes as well as to better nutrition
School Health Steering Committee: An inter-sectorial school health steering committee comprised of
members mainly from the Ministries of Health, Education, Women and Children, Youth and Sport,
Water Resources and other relevant stakeholders
Health communication: The study and practice of communicating promotional health information, such
as in public health campaigns, health education, and communication between doctor and patient to
influence personal health choices by improving health literacy
Health Extension Program (HEP): A defined package of basic and essential preventive and selected
high impact curative health services targeting households and communities
Health literacy: The degree to which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health decisions
Health promotion: The process of enabling people to increase control over their health and its
determinants, and thereby improving their health
School health center (የትምህርት ቤት ጤና ማዕከል): Primary care centers based in both public and private
school at all levels to provide a combination of health promotion, basic curative service and referral
Ethiopia School Health Program Framework 6

Table of contents
Forward ......................................................................................................................................... 1
Acknowledgements ....................................................................................................................... 2
Acronyms and abbreviations ....................................................................................................... 3
Operational definitions ................................................................................................................. 5
Table of contents ........................................................................................................................... 6
1. Introduction ............................................................................................................................... 8
2. Background ............................................................................................................................... 9
3. Situational analysis ................................................................................................................. 12
3.1. Social behavioral change communication and life skills to promote healthy lifestyles............ 13
3.2. School nutrition .............................................................................................................................. 14
3.3. Water, sanitation and hygiene (WASH) ...................................................................................... 15
3.4. Common infections, infestations and disorders........................................................................... 16
3.5. Vaccination and immunization ..................................................................................................... 20
3.6. Sexual and Reproductive Health .................................................................................................. 21
3.7. HIV and sexually transmitted infections ..................................................................................... 22
3.8. Mental, neurological & substance use disorder .......................................................................... 23
3.9. Non-communicable diseases and injuries .................................................................................... 24
3.10. School health during education in emergency ........................................................................... 26
4. SLOT analysis ......................................................................................................................... 26
5. Rationale .................................................................................................................................. 27
6. Strategic framework ............................................................................................................... 28
6.1. SHP objectives ................................................................................................................................ 28
6.2. Scope of the SHP and alignment with existing strategies ........................................................... 28
6.3. Guiding Principles of the SHP Framework ................................................................................. 28
6.4. Strategic Principles and Approach ............................................................................................... 29
6.5. Conceptual framework and logical score card ............................................................................ 30
7. SHP Packages .......................................................................................................................... 34
Package 1: Social and Behavioral Change Communication (SBCC) and life skills development . 34
Package 2: School Nutrition Services .................................................................................................. 35
Package 3: Water, Sanitation and Hygiene (WASH) ........................................................................ 36
Package 4: Management of common infections, infestations and disorders ................................... 36
Package 5: Routine and catch-up provision of vaccinations and immunizations ........................... 37
Package 6: Sexual and reproductive health (SRH) services.............................................................. 38
Package 7: HIV/STI prevention and control services ........................................................................ 38
Package 8: Mental, neurological and substance use (MNS) disorders prevention and support .... 39
Package 9: Prevention and control of non-communicable diseases (NCDs) and injuries .............. 39
Package 10: School health preparedness, response & recovery during education in emergency . 41
Ethiopia School Health Program Framework 7

8. Implementation modality ....................................................................................................... 41

8.1. Human resources and infrastructure ........................................................................................... 41
8.2 Supplies, equipment and drugs ...................................................................................................... 42
8.3 Program financing .......................................................................................................................... 42
8.4 Monitoring, evaluation and research ............................................................................................ 43
8.5 SHP service linkage......................................................................................................................... 44
9. Leadership and governance ................................................................................................... 46
10. References .............................................................................................................................. 54
Annex 1: Pre-primary gross enrollment, by region and gender (age 4 – 6 years) ................ 56
Annex II: Primary gross enrollment by region and gender (Grades 1-8) ............................. 57
Annex III: Secondary Gross Enrollment by region and gender (Grades 9-12) .................... 58
Annex IV: Number of schools with and without clinics (MoE 2015/16 G.C.) ....................... 59
Annex V: Detailed School Health Program Packages ............................................................. 60
Annex VI: M & E Indicators for SHP .................................................................................... 109
Annex VII: Stakeholder Analysis ............................................................................................ 114
Annex VIII: Detail program costs ........................................................................................... 118
Ethiopia School Health Program Framework 8

1. Introduction
Globally, the concept of school health has evolved over a period several decades. The World Health
Organization (WHO) has supported implementation of the school health concept worldwide since 1995.
In 2000, UN agencies, including WHO, UNESCO, UNICEF, and the World Bank organized a strategy
session at the World Education Forum in Dakar, Senegal to raise awareness of school health among the
education sector and made a strong case of the value of school health in achievement of ‘Education for
All’. School health programs (SHPs) increase the efficacy of other investments in child development,
ensure better educational outcomes, increase social equity and are highly cost effective.

Nigeria and South Africa are two African countries that have long-term experience implementing SHPs.
Nigeria developed a National School Health Policy that provides strategic guidance to the implementation
of SHPs in the country. South Africa established a Health Promoting Schools Committee with
representatives from Education Ministries in order to introduce and implement the SHP, which addresses
health issues such as road safety, personal hygiene, substance use, HIV and nutrition through teenage
clubs, outdoor camps, and teacher support groups. Inter-sectorial approaches were employed in both
cases.

Between 2002 and 2007 E.C., the net education enrollment rate has increased from 86.6% to more than
94% in Ethiopia, which shows that an increasing number of young people are attending school. The
majority of Ethiopia’s 37 million school aged population is currently attending schools. The Government
of Ethiopia has designed and implemented different policies and strategies in order to reach the school
age population, such as designated some schools as priority service delivery points for the HEP and
providing for adolescent- and youth-friendly sexual and reproductive health services in youth centers and
health facilities throughout the country. The Woreda Transformation Agenda, as part of the Health Sector
Transformation Plan (HSTP), emphasizes school health as one of the criteria for a model Kebele.
Additionally, the strategic initiative set by the HSTP to implement the second generation health extension
program (HEP) includes strengthening school health services.

In Ethiopia, there have been several programs and strategic plans meant to address the health needs of
children, adolescents, and youths. The Health Extension Package (HEP) has emphasized school health in
its packages at the Kebele level. In addition, the National Adolescent and Youth Health Strategy, first
launched in 2006 and again revised in 2016, contains service and intervention packages to address
adolescent and youth sexual and reproductive health needs. The MoE launched the National School
Health and Nutrition Strategy in 2012.

All pre-primary and primary schools and the majority of secondary schools in Ethiopia do not currently
have school based health services. Unlike lower level education in Ethiopian, universities already have
health clinics and health clubs staffed with a limited number of health professionals and counselors who
can provide comprehensive health services to students. There are, however, newer initiatives within
Ethiopia that target schools as the point of service, such as the provision of HPV vaccines to adolescent
girls and the roll-out of school feeding programs in some areas. Additionally, there are other vertical
programs implemented at schools with the support of local and international organization. These
initiatives lay the foundation for the establishment of a comprehensive SHP that can fully address the
needs of Ethiopian students’ health.
Ethiopia School Health Program Framework 9

Even though the above interventions are being implemented in the country, major gaps still exist in
providing comprehensive school health services around basic knowledge and life skills to school children
and adolescents across all levels in Ethiopia and limited, vertical program implementation may result in a
duplication of efforts. Therefore, a comprehensive school health approach is needed to encourage each
school to look at its whole school community and develop an encouraging environment and culture that
promotes healthy ways of living standards.

The MoE developed and launched the National School Health and Nutrition Strategy in 2012 with the aim
of improving access to educational achievement of school children through health and nutrition
interventions within educational institutions. In line with the other existing health related policies, such as
the HIV policy, the HSTP, the HEP, the Health and Nutrition Strategy, and the HIV intervention package,
the new comprehensive SHP outlined below will bring together ten school health service packages:.
Social behavioral change communication and life skills training to promote healthy lifestyles; Nutritional
status assessment, counseling and support; Water sanitation and hygiene (WASH); Management of
common infections, infestations and disorders; Routine and catch up vaccination program; Sexual and
reproductive health services; HIV/STI prevention and control services; Mental, neurological and
substance (MNS) use disorders prevention and management; Prevention of non-communicable diseases
(NCDs) and injuries; and, school health preparedness, response and recovery during education in
emergency.

2. Background
Ethiopia is a vast and diverse country with the second largest population in Africa, estimated at over 93
million in 2016 (CSA Projection 2013) and increasing at an average annual rate of 2.6%. The pyramidal
age structure of the population remains young as school children (ages 5 to 9), adolescents (10 to 19) and
youth (15 to 24) together constitute 46.5% (over 43 million) of the Ethiopian population.

Ethiopia has a federal system of governance, nine regional states and two city administrations. The
Regional States have considerable authority and responsibility, ensured by the constitution, and exercised
and discharged through councils at Region, Zone, Woreda and Kebele levels. Health and education are
the shared responsibilities of each of these administrative tiers.

The Government of Ethiopia (GoE) has invested heavily in health system strengthening, guided by the
country’s policies and strategies, resulting in significant improvements in the health status of Ethiopians.
As a result, Ethiopia has done remarkably well in meeting most of the Millennium Development Goals
(MDG) targets. Of note is the achievement of MDG-4 with a 72% reduction in under-five mortality from
the 1990 estimate. The significant reduction in child mortality has significantly contributed to an increase
in average life expectancy at birth from 45 years in 1990 to 64 years in 2014. Additionally stunting and
underweight in children less than five has decreased in the past two decades from 58% to 38% and from
41% to 23%, respectively (EDHS 2016).

Even though the nation has achieved impressive reductions in morbidity and mortality and increased
overall access to primary health care, high regional disparities remain in the majority of health outcome
Ethiopia School Health Program Framework 10

indicators, driven by differences in the social determinants of equity such as gender based violence
(GBV) and harmful traditional practices (HTPs), economic and educational status, access to basic
utilities, poor network of roads and food security. The government has recognized these challenges and
strategized to provide special support to regions and Woredas that are lagging behind from the others in
the majority of health development indicators.

The significant gains made are as a result of the political commitment and strong leadership at all levels
of government, as well as community engagement and ownership of health programs including school
health. The country’s flagship program, the Health Extension Program (HEP) has been the principal
vehicle to expand access to essential health service packages to all Ethiopians, with a specific focus on
women and children. Over the last 20 years, the country has successfully implemented its strategy of
expanding and rehabilitating primary health care facilities. More specifically, 16,440 health posts, 3,547
health centers and 311 hospitals are providing health service to the population. The Ethiopian health
service system is structured as a three-tier system:

Primary level health care is composed of a primary hospital (PH), health center (HC), and five
satellite health posts (HP). The PH provides inpatient and ambulatory services to an average
population of 60,000 - 100,000. The HC serves a catchment population ranging from 15,000 - 25,000
people in rural areas and 40,000 people in urban areas. The HC is expected to provide both preventive
and curative services and serve as referral centers and practical training site for Health Extension
Workers (HEWs). The HP is the lowest level of Ethiopian health care system staffed by two HEWs
each per Kebele and expected to serve a catchment population of 3,000 – 5,000 people;
Secondary level health care comprises a general hospital which provides inpatient and ambulatory
services to an average of 1 million – 1.5 million people;
Tertiary level health care is composed of a specialized hospital that serves an average of 3.5 million -
5 million people and serves as a referral center from general hospitals.
Ethiopia School Health Program Framework 11

F IGURE 1 THE THREE- TIER HEALTH SYSTEM OF ETHIOPIA

Similar to the health system, the current Ethiopian education system is multi-tier:

Pre-school programmes are delivered through three modalities. The first, kindergarten, is
predominantly operated by non-governmental organizations (NGOs), communities, private
institutions, and faith-based organizations. The second, non-formal pre-school service, is delivered
mainly through the child-to-child initiatives. The third modality, the setting up of ‘O’ class, is the
most widespread and responsibility of local governments.
Primary education is classified as primary first cycle which encompasses grade 1-4 and primary
second cycle from grade 5- 8.
Secondary level of education is categorized as secondary first cycle for grade 9-10 and the secondary
second cycle from grade 11-12, is also called preparatory schooling.
Technical and vocational education and training (TVET) is another level of education that is
delivered at levels ranging from level one to five and intended for those students who have completed
grade 10.
Undergraduate and postgraduate degree program.

Through this system, a total of 37,325,971 students have been enrolled at different levels of the Ethiopian
education system (MOE 2015/16). Out of these, 13,581,208 are pre-school students, 19,977,441 are in
primary school, 2,421,163 are in secondary school, 515,872 are in TVET and colleges of teacher
education (CTE) schools, and 830,287 students are in higher education (college and universities). The
number of enrolled students has dramatically increased over time. Detailed school enrollment can be
found in Annex I – III and below in Figure 2.
Ethiopia School Health Program Framework 12

As of 2008 E.C., EMIS data shows that there are a total of 4,391 pre-schools, 34,867 primary schools and
3,156 secondary schools owned by the government, NGO or private sector. The number of universities in
the country has been increasing and currently stands at 37 public universities. There are also 98 private
colleges, 36 colleges of teacher education (CTEs) and 919 technical and vocational education and training
schools (TVETs).

F IGURE 2 S CHOOL GROSS ENROLLMENT (MO, 2008 E.C., 2015/16 G.C.)

Level of education Male Female Total

Pre-primary (KG or O class) 7,236,606 6,344,602 13,581,208
Primary (1-8) 10,569,951 9,407,490 19,977,441
Secondary (9-12) 1,276,046 1,145,117 2,421,163
CTE 126,320 85,413 211,733
TVET 146,163 157,976 304,139
Higher ( University & College) 552,536 277,751 830,287
Total 19,907,622 17,418,349 37,325,971

The number of primary and secondary schools that have the infrastructure for a clinic within the school
compound varies from region to region, but currently only one–in–four secondary schools has a clinic
infrastructure. There are also significant disparities in terms of the extent and quality of health services
provided at the school clinics. Many of the clinics in secondary school provide basic first aid services
only. Detailed information on school clinics is available in Annex IV.

3. Situational analysis
A review of existing literature, surveys and guidelines was conducted in order to assess the situation of
health, disease/disorder burden within the context of existing school circumstances. The situational
analyses were framed in line with the SHP packages to be delivered at all pre-primary, primary,
secondary and tertiary levels. The following situational analyses each relate to the SHP packages, which
are broadly grouped as follows:
1. Social behavioral change communication and life skills to promote healthy lifestyles
2. School nutrition
3. Water, sanitation and hygiene (WASH)
4. Common infections, infestations and disorders
5. Vaccination and immunization
6. Sexual and reproductive health
7. HIV and sexually transmitted infections
8. Mental, neurological and substance use disorder
9. Non-communicable diseases and injuries
10. School health during education in emergency
Ethiopia School Health Program Framework 13

3.1. Social behavioral change communication and life skills to

promote healthy lifestyles
The National Health Promotion and Communication Strategy (2016-2020) indicates that further health
improvements in Ethiopia are possible with improved awareness and adaption of healthy behavior, which
can be facilitated through social and behavioral change communication (SBCC) approaches. The Strategy
also indicates that adolescents’ and young people’s low health service utilization is driven by preferences
and health seeking behaviors, a lack of youth friendly services, poor communication, and providers’
attitudes and competencies, as well as other socio-cultural impediments. The Strategy emphasizes the
need to put in place comprehensive SBCC interventions that target behavior change at community and
household levels to address the increasing ‘triple burdens’ from communicable diseases, non-
communicable diseases, and injuries and accidents.

School-based SBCC interventions that address students’ awareness and behavior regarding communicable
diseases, including reproductive health, HIV and non-communicable diseases, are limited in Ethiopia.
However, in Ethiopia, the prevalence of teenage pregnancy is 13% and there are an estimated 500,000
unsafe abortions each year (National Health Promotion and Communication Strategy 2016). In addition,
comprehensive knowledge about HIV is low among young women (24.3%) and men (39.1%) aged 15-24
years (EDHS 2016).

There has been no comprehensive assessment of the effectiveness and contribution of SBCC programs
currently implemented in schools to provide health information and improve students’ health status.
Modalities for SBCC include group discussions/school community conversation, life skills and peer
education, youth dialogue, use of IEC/SBCC materials, mini-media and entertainment programs, student
clubs and other curricula activities.

Thus, it is crucial for this program to focus on the gaps in existing health programs, including behavioral
and non-behavioral factors and individual-level determinants of health by strengthening school
community empowerment and engagement, and by creating an enabling environment in order to sustain
positive health behaviors and outcomes.

Life skills are a group of psycho-social and interpersonal skills, which can help people to make informed
decisions, communicate effectively and develop coping and self-management skills that may help an
individual to lead a healthy and productive life. Life skills can have significant health and social benefits
for school children. They can help students transition successfully from childhood to adulthood by
developing healthy lifestyles. They also equip students with skills to negotiate difficult or risky situations
and equip students with problem solving and mediation skills. In addition, life skills help students
differentiate between skills of learning, hearing and listening, and therefore help reduce instances of
misconception or miscommunication regarding issues such as drugs, alcohol use and early sexual debut.

Schools are an appropriate place for the introduction of life skills education as they play an important role
in the socialization process of an individual. In addition, schools are an economically efficient way of
reaching out to young people by making use of existing infrastructure. It is also a place where children
and adolescents can easily be reached on a larger scale. Experienced and influential teachers can serve as
role models as they practice and exercise life skills and capitalize on their high level of credibility with
Ethiopia School Health Program Framework 14

parents and other community members. Life skills development in school also contributes to creating an
enabling environment for learning and self-development and lays a strong foundation for the future life of
the students through building self-confidence, resisting peer pressure and fostering respect for themselves
and others.

Although there is very little life skills education at present in Ethiopia, there is rich experience from other
countries. Despite the general practice of providing life skills education in secondary schools, global
evidence has shown that life skills education provided in primary schools is very effective in bringing
both adaptive and positive behavior changes that enable individuals to deal effectively with the demands
and challenges of everyday life. Life skills education focused on communication and interpersonal
negotiation/refusal, decision-making and critical thinking, coping mechanisms and building self-
confidence has been shown as successful.

In the Ethiopian context, adolescents face risk of substance use (e.g., alcohol, tobacco, and khat), early
sexual initiation, and teenage and unintended pregnancy, potentially resulting unsafe abortion. This is
mainly due to lack of information, education, services and skills that help them make informed decisions.
These problems are often addressed by life skills development to equip students to mitigate peer pressure
and improve decision-making and control other social and emotional factors that may influence them.

3.2. School nutrition

School children are often thought of as naturally healthy, but in many areas in Ethiopia, school children
are stunted, underweight, wasted, anemic and deficient in zinc, vitamin D, iodine and vitamin A. In many
areas, school children are affected by health- and nutrition-related problems that constrain their ability to
thrive and limit their ability to attain their education potential. These inadequate nutritional conditions,
highly prevalent in a number of Ethiopian regions are all believed to lead to impaired cognitive ability.
The EDHS 2016 indicates that in Ethiopia 38.4% of children are stunted and 23.6% of children are
wasted with strong rural-urban disparities.

Studies show that providing meals at schools improves scores on arithmetic tests by increasing regular
attendance and improving cognitive capacity (Simeon 1998). Missing breakfast impairs learning
performance to a greater extent for children of poor nutritional status. Stunted children enroll in school
later than non-stunted children (Bundy et al 2006). The Cost of Hunger Study in Ethiopia (COHA 2013)
revealed that 16% of all primary school grade repetitions in 2009 were associated with stunting and that
stunted children achieve on average 1.1 years less in school education. The study further estimated
Ethiopian’s annual economic cost due to school repetition is about 93 million ETB. The study showed
that ill health and malnutrition affect access to education, participation, completion and achievement.

Micronutrient deficiencies, commonly called “hidden hunger”, take a longer time than protein-energy
malnutrition to manifest physically and visibly. Micronutrient deficiencies have a significant impact on
children’s cognitive and physical growth and school performance. At the global level, micronutrient
deficiencies are major public health concerns, of which the key deficiencies are vitamin A, iron, iodine,
and in more recently, zinc. Vitamin A, zinc and iron deficiencies account for 19% of the 10.8 million
global child deaths annually (WHO 2002). In terms of the number of children suffering from
micronutrient deficiencies, reports note that worldwide 85 million school-age children are suffering from
Ethiopia School Health Program Framework 15

vitamin A deficiency, 210 million from iron deficiency anemia, and 60 million children are affected by
iodine deficiency (Drake et al 2002).

Iron, zinc and iodine deficiencies have been linked to poor cognitive development and poor educational
performance. Children with iron deficiencies are less likely to attend school. Vitamin A deficient children
have a weakened immune system, visual defect and an increased risk of dying from diarrhea, malaria and
measles and zinc-deficient children experience growth failure as well as weakened immunity (Nederveen
2010).

The National Food Consumption Survey clearly indicated that Ethiopian’s consume both macro- (protein
and fat) and micro-nutrients (Calcium, vitamin A, folic acid, zinc, etc.) at levels far below the
Recommended Daily Allowance (RDA) (EPHI 2013). The survey also indicated that in all age groups
people’s daily calorie intake was almost exclusively based on cereals and animal-based food products.
The proportion of households consuming from five or more food groups was found to be only 20% (EPHI
2015).

The National School Health Nutrition Survey also found a 12.8% prevalence of night blindness among
school children and adolescents (MOH 2008). The recent National Micronutrient Survey indicated a
subclinical vitamin A deficiency among 10.9% of adolescents. The same study showed a 25.6%
prevalence of anemia adjusted for altitude among school-aged children (5 to 14 years). Micronutrient
deficiencies were more prevalent among rural residents and pastoral communities (EPHI 2016). The
national prevalence of zinc deficiency was found to be 36% in the same age group (5 to 14 years). The
prevalence of iodine deficiency, as measured by mean urinary iodine concentration below the cut off (100
μg/L), was 48%, despite the fact that iodized salt coverage at household level is 85%. The survey also
found a goiter prevalence of 3.7% in school age children with strong regional disparities. In general,
school-based health programs can provide a cost-effective and low-cost solution to address nutritional
deficiencies.

3.3. Water, sanitation and hygiene (WASH)

Global evidence suggests that the provision of safe and adequate water supply, improved sanitation
facilities and safe hygiene practices are essential services and interventions in schools. This is because
schools without adequate water, excreta disposal and hygiene services create high-risk environments for
children and staff, and thus exacerbate children’s particular susceptibility to environmental health
hazards. Children’s ability to learn may also be affected by inadequate sanitation and hygiene services in
several ways; for instance, through creating breeding sites for harmful insects, helminthes, bacteria and
viruses (NHN Strategy 2012).

A number of studies showed that each year children lose 272 million school days due to diarrhea and that
an estimated one in three school-age child in the developing world are infested with intestinal worms.
Further, the average IQ loss per worm infestation was 3.075 points, representing 633 million IQ points
lost for people who lived in the world’s low-income countries (Hutton and Laurance 2004).

The majority of primary schools in Ethiopia have sanitation facilities, with 86% having some toilet or
latrine provision. However, the majority are traditional pit latrines and only 31% of school toilets or
Ethiopia School Health Program Framework 16

latrines are classified as ‘improved sanitation’. Many schools lack adequately separated facilities for boys
and girls, as well as provisions for special needs and young age groups. As a result of inadequate
sanitation provision, only about half (49%) of all schools are considered to be free from open defecation.
Hand washing is equally vital to ensure a healthy school environment for the school community. Only
about one fifth of primary schools (21%) report having hand washing facilities and only 5% have soap.
Hygiene education activities (including menstruation care) are currently undertaken in few schools.
Provisions for menstruating girls are only available at 20% of primary schools.

The same data source also indicated that most secondary schools have some sanitation facilities, with
87% having some toilet or latrine provision. However, a lot of provisions are traditional pit latrines with
only 41% school toilets or latrines are classified as improved. Hand washing provision is somewhat better
than in primary schools, but still only about half of secondary schools (46%) report having hand washing
facilities and only 7% have soap. Hygiene education is provided in two thirds (68%) of secondary
schools. The ‘Safe WASH at Schools’ Indicator combines indicators in the questionnaire to identify
schools that have a protected water source which is functional and meets demand, as well as improved
latrines and hand washing facilities; only 10% of schools meet this standard.

3.4. Common infections, infestations and disorders

Despite an overall increase in coverage and quality of child health services delivered through existing
strategies, health care utilization remains low due to barriers to access and limited demand. In order to
achieve the full potential of demand-generation activities for accessing and utilizing health care services,
targeting major school-age diseases while at schools can play a critical role. The common school-age
childhood diseases and disorders are outlined below.

3.4.1. Intestinal infections and infestations

Soil transmitted helminthes infections are among the most prevalent intestinal infestations in developing
countries. Generally, these parasites are most common in areas with tropical climates. The most prevalent
intestinal infestations include Ascariasis, Enterobius Vermicularis, Hymenolepis and hookworm
infestations. School age children are among the most vulnerable group to be exposed for intestinal
parasitic infestations. For many children, going to school is the first opportunity to come in contact with
people other than close relatives and neighbors. Consequently, school enrollment may also represent the
first exposure to a range of infectious diseases.

Worms do not reproduce in human body but produce eggs, which then contaminate the environment,
including water and soil. People who use contaminated water for drinking and sanitation and those who
walk barefoot are often prone to worm infection and infestation. Children are particularly susceptible to
worm infection due to the fact that children’s behaviors make them vulnerable to oral-fecal and or soil-to-
skin contact, increasing the likelihood of worm infection. Such infections predispose students to anemia
and malnutrition and other co-infections. Worms can be diagnosed microscopically and treated
accordingly. However, individual diagnosis is much more expensive than treatment. Hence, periodic
anthelminthic treatment as a part of child health services in schools plays a crucial role in protecting
children from worm/parasitic infections.
Ethiopia School Health Program Framework 17

The WHO estimates that over 270 million pre-school children and over 600 million of school children are
living in areas with high levels of parasite transmission and are in need of treatment and preventive
interventions (WHO Neglected Tropical Diseases 2010). Intestinal helminthes contribute to about 39
million disability adjusted life years and thus result in substantial economic loss. Moreover, intestinal
obstruction and related abdominal complications caused by large adult worms contribute to preventable
child deaths.

In Ethiopia, intestinal parasitic infections increase susceptibility to other infections, are among leading
causes of mortality and morbidity and related to public health problems such as malnutrition, anemia, and
growth stunting. Evidence from a variety of studies shows that intestinal parasites are prevalent in varying
magnitudes among school children in Ethiopia. In eastern Ethiopia, the overall prevalence of intestinal
helminthiases was estimated at 27.2% with Hymenolepis Nana, hookworm and Schistosoma amansoni
contributing to half of the burden. Additionally, prevalence as high as 60% was reported in studies in
other parts of the country. Prevalence is closely related with low income, poor personal hygiene, poor
environmental sanitation, lack of pure water supply, limited access to clean water, lack of regularly
wearing shoes and low altitude. Therefore, health information dissemination and SHPs should focus on
personal hygiene, in particular the benefits of washing hands after defecation and the health benefit of
wearing shoes in particular for very young children.

Helminthiases, which have significant effect on body iron status, are widespread in the country. Close to
23 million school age children live in areas with high infection rates and therefore qualify for anti-
helminthes treatment. In the first Mass Drug Administration (MDA) in 2007, one million school-age
children were dewormed for soil-transmitted Helminthiases (STH) and Schistosomiasis, while 6.8 million
and 7.8 million school-age children received similar treatments in 2013 and 2014, respectively. Although
deworming is mainly done in schools for the specified age group, children between the same age group
who are not enrolled in schools also need to be treated.

3.4.2. Fungal and bacterial skin infections

Global evidence shows that there is a significant burden of skin disease in school age children of which
infectious dermatoses are most common. The common skin conditions that prevail among school age
children include fungal infections, bacterial infections, such as impetigo, and parasitic skin diseases.

The situation is similar in Ethiopia; a retrospective analysis performed on 17,967 medical records of
children aged 0 to 18 years attending the Dermatological Centre in Mekele from January 2005 to
December 2009 showed that skin infections and infestations accounted for 47% of the disorders seen.
Fungal infections were the most common (44.1%), followed by bacterial and parasitic diseases.
Dermatitis constituted the second most common diagnostic category (24.7%), with contact dermatitis was
the most common diagnosis (48.8%) within the category. (Marrone R et al 2012). A 30% rate of
tineacapitis was reported in one study among school children (Figueroa JI et al 1997).

Given the overall high prevalence of these contagious skin problems in school age children, it is
imperative that SHPs be inclusive of active case finding approaches and preventive measures to curb the
existing prevalence of fungal and bacterial skin infections.
Ethiopia School Health Program Framework 18

3.4.3. Skin infestation

Studies report that the prevalence of ectoparasites (skin infestations) is still a public health problem
affecting school children. Among the common skin infestations are head lice, scabies, Meiosis and
Tunisair. These forms of ectoparasitosis are a major health concern in schools as well as in the wider
community.

In school-aged children, head lice infestation can cause sleep disturbances and concentration difficulties,
potentially leading to poor performance in school, social distress, discomfort, parental anxiety,
embarrassment, and unnecessary absence from school. In developing countries, persistent infestation has
also been associated with high morbidity, including secondary infections and impetigo. Tungiasis can also
be incapacitating especially due to severe physical disability emanating from its pathological effects of
severe itching, pain and sensation of a foreign body on the skin. A survey undertaken in school children in
southwest Ethiopia found that infestations were the most prevalent skin pathology followed by fungal
infections, thus making it a disease of significant health concern (Figueroa JL et al 1996)

Given that schools are usually the first time children are exposed to varying highly contagious diseases,
periodic screening among students is obligatory in a SHP to establish a healthy school environment.

3.4.4. Upper respiratory tract infections (URTIs) with emphasis on rheumatic heart disease
Acute rheumatic fever (ARF) and its sequel rheumatic heart disease (RHD) continue to cause significant
morbidity and mortality in developing countries and have been under-recognized as a global health
problem for decades. Overall global burden estimates show that there are 471,000 annual cases of ARF,
with an incidence in children aged 5 to 15 years ranging from 10 cases per 100,000 in industrialized
countries to 374 cases per 100,000 in the Pacific Region. The overall burden of RHD is estimated to be
15.6 million prevalent cases with 282,000 new cases and over 233,000 deaths per year (Carapetis JR et al,
2005).

The highest prevalence of RHD is in Sub-Saharan Africa (SSA) with a prevalence of 5.7 per 1,000
children, compared with 1.8 per 1,000 in North Africa, and 0.3 per 1,000 in economically developed
countries with established market economies (WHO 2007).

Ethiopia is one of the high burden countries for RHD in SSA. According to one study, the prevalence of
RHD in school-age children between 13 to 15 years ranges from 6.4 per 1,000 and 7.1 per 1,000 children.
Consistent with observations from elsewhere in the world, the burden of ARF and RHD in Ethiopia is
higher among the poor, and is more common in rural than urban areas, except in urban slums.

Prevention of RHD can be achieved through the control of ARF. Effective methods of controlling ARF
and RHD include prompt and adequate treatment of suspected or confirmed Group A Streptococcal
Pharyngitis with penicillin before the occurrence of ARF (primary prevention), and long-term regular
administration of penicillin to prevent recurrent ARF (secondary prevention), since the majority of RHD
are a result of recurrent ARF. But as it is the case in most countries in SSA, primary and secondary
prevention strategies have not been fully implemented in Ethiopia. While challenges to controlling the
epidemic of ARF and RHD in Ethiopia are many, if not insurmountable, the above-mentioned proven and
cost-effective means of controlling the problem do exist.
Ethiopia School Health Program Framework 19

As schools play a large role in spreading streptococcal infection, they can also play a large role in its
control. Where school health services exist, they should be used to identify children with signs suggestive
of ARF. Screening school children for ARF is worthwhile in areas with a high prevalence of RHD, which
can be carried out by primary health care workers. Hence, through a SHP, it is possible to boost the
preventive, early case identification and appropriate treatment interventions that are crucial in addressing
this preventable child health problem.

3.4.5. Eye health

Around the world, an estimated 19 million children are visually impaired and are officially classified as
either blind or with low vision. Of these, 12 million children are visually impaired due to refractive errors,
which is easily diagnosed and corrected with a pair of glasses. In addition to refractive errors, primary
school age children may be affected by allergic eye disease, conjunctival infections, including trachoma,
and eye injuries. Some children may have more serious conditions, which require surgery, such as
cataracts. Other children may have conditions associated with permanent vision loss. Ethiopia has one of
the highest prevalence of active trachoma, which remains a major health problem, and a leading cause of
blindness. The trachoma survey carried out by the Global Trachoma Mapping Project (GTMP) in 2013
revealed that trachoma is endemic in 604 rural Woredas with around 73 million people at risk of
infection.

In addition, the prevalence of blindness and low vision in Ethiopia is one of the highest in SSA. In
Ethiopia, cataracts are responsible for around half of all blindness with other major causes being trachoma
(11.5%), other corneal opacities (7.8%), refractive errors (7.8%) and glaucoma (5.2%). Similarly, the
major causes of low vision are cataracts (42.3%), refractive errors 33.4% and trachoma 7.7% (HSTP).
Among children visiting a tertiary eye center at Jimma University Hospital, the most common childhood
ocular diseases diagnosed in 2010 were ocular surface and eyelid infections (30.5%), ocular allergies
(28.1%), ocular traumas and injuries (15.5%) and refractive errors (5.8%).

Avoidable eye diseases accounted for about 97% of ocular morbidities. Children with sight problems
must be provided with spectacles, low vision devices or medical intervention (Vision 2020). Refractive
services in schools, especially in primary schools for children aged 7-15 years, could contribute a great
deal to relieving this burden. By 2015, the total number of schools performing screening had reached
1,750; however only 250,000 students were screened and only 25,000 students received eye glasses (MoH
Health Strategic Plan 2016).

3.4.6. Hearing defects

Recent WHO estimates indicate that 32 million children across the world live with disabling hearing loss.
Disabling hearing loss is unequally distributed globally with SSA accounting for 9% of the total burden.
In children, prevalence of hearing defects decreases exponentially as GNI increases. In most regions,
prevalence in children decreases linearly as parental literacy rates increase.

In a community based survey in rural eastern Ethiopia in 2014, hearing loss was the most frequent
disability among children aged 0 to 14 years. Among these students almost half of them had chronic ear
discharge and the majority of children had treatable hearing problems. One of the main impacts of hearing
loss is a child’s ability to communicate with others. Spoken language development is often delayed in
deaf children. Hearing loss and ear diseases such as otitis media can have significantly adverse effects on
Ethiopia School Health Program Framework 20

the academic performance of children (WHO 2012). Around half of all cases of hearing loss and deafness
are avoidable through primary prevention and many cases can be treated through early diagnosis and
suitable management.

3.4.7. Oral health

The major oral health problems include dental caries, periodontal disease, malocclusion and dental
fluorosis. The most common chronic dental diseases in children worldwide are dental caries (tooth decay)
and gum disease (gingivitis). Across the world, dental caries and gingival bleeding, indicative of
gingivitis, affect 60% to 90% of school children. In Ethiopia there is very little epidemiological research
available. In one study conducted in Addis Ababa in 2000, periodontal disease affected more than half
(53.4%) of the study subjects and was significantly higher in males, those with high consumption of
sweets, those having 'injera' as staple diet and those with poor oral hygiene. The prevalence of
malocclusion was 23.7%, while crowding and spacing of teeth were found in 23.8% and 18.3% of the
subjects, respectively. The prevalence of dental fluorosis was low (1.6%). Another study conducted
among marginalized children aged 6 to 15 years in Addis Ababa indicated that prevalence of dental decay
and gum disease was significantly high in HIV positive and orphaned children.

Most dental caries in children remain untreated and may have general health consequences. Diseases of
teeth and mouth affect children’s ability to eat and chew, the food they choose, their appearance and the
way they communicate. Pain from teeth and the mouth can compromise children’s attention and their
ability to learn at school, thereby hampering, not only their play and development, but also denying them
the full benefit of schooling. The essential risk factors involved with mouth disease among children and
young individuals relate to an unhealthy diet, in particular those high in sugar consumption, poor oral
hygiene, and use of tobacco and alcohol. Lack of sanitary facilities and clean water, lack of experience in
promoting health and prevention of mouth diseases among school teachers, lack of health education tools
and isolation of oral health from school curricula contribute to poor dental hygiene. In addition, lack of
school health services may limit the control of mouth diseases in schoolchildren. Lack of referral of
children for dental care is another factor, which may limit prevention and treatment of mouth diseases.

3.4.8. Physical disability

Children with disabilities may suffer from long-term physical, mental, intellectual or sensory impairments
that may hinder their full, effective and equal participation in society. Although disability is believed to be
prevalent among children in Africa, official statistics are unavailable either due to lack of reliable data or
due to an attempt to conceal the extent of the problem. Most countries in Africa depend on UN estimates,
which reported about 5% of children in the age bracket of 0 to14 years as having one or more disability.

3.5. Vaccination and immunization

Immunization is among the most cost effective infection prevention methods and is an established public
health intervention. Its introduction in Ethiopia dates back to 1974 with limited antigens against six major
childhood infections. The scope of immunizations in Ethiopia has expanded to more than 11 antigens
with the introduction of new vaccines.

In Ethiopia immunization coverage with specific antigens has shown a progressive increase in the past
years. The most recent WHO and UNICEF estimates of national immunization coverage (wuenic) for
Ethiopia School Health Program Framework 21

2015 shows 86% and 78% coverage for the third dose of Diphtheria-Pertussis-Tetanus (DTP3) and the
measles vaccine, respectively. The 2016 EDHS assessed tetanus toxoid vaccination coverage in women of
reproductive age through the proxy indicator of infants protected at birth, showing that only half (49%)
were protected from neonatal tetanus risk. The Human Papilloma Virus (HPV) vaccination demonstration
project in two districts used schools and other existing platforms for immunization and (Gomma, Jimma
zone and Ahferom, central Tigray) from 2015 - 2017 showed high coverage rates for girls aged 9 to14
years. Even though Ethiopia’s overall immunization coverage continues to increase at the national level,
there are regional disparities with lower coverage of key antigens in pastoral and rural areas. The recent
EDHS confirmed this trend. There is a significant opportunity for the integration of immunization
screening and service linkages with vaccines into schools in order to advance immunization coverage in
the country.

Having an established school platform for immunization will provide a modality for immunization catch
up in early school years and will increase the potential uptake of current vaccines as well as those that
will be introduced in the near future, such as HPV. This will reduce the rate of accumulation of
susceptible children and the risk of an outbreak of the particular disease.

3.6. Sexual and reproductive health

Adolescence is time when physical, social, and emotional changes occur in the life of any child.
Adolescent is also characterized by the development of secondary sexual characteristics, including
menarche among girls. It is also an important time to lay a strong foundation for education, build positive
health behaviors and critical thinking skills. Access to comprehensive reproductive health (RH) services
provides support and protects students from multifaceted RH problems during that critical time of
transition.

However, evidence shows that lack of access to RH information, education and services negatively affects
the health of students and may lead to physical problems, guilt, ambiguity, and confusion related to
changes in their bodies. Girls also need a safe space, friendship and support networks and older girls and
women as role models (Population Council 2011; Browne 2014). In developing countries, particularly in
Africa, pregnancy and delivery related complications are the second most common causes of deaths
among adolescents (10 to19 years) next to injury, violence, and infections (UNFP 2012). The most
common factors associated with morbidity and mortality of adolescents and youth in Ethiopia includes
early sexual debut, risky sexual practices, child marriage, early child bearing, unintended pregnancy,
unsafe abortion and STIs, including HIV.

A study conducted among university students in Jimma showed that students have inadequate and
fragmented knowledge on sexual and reproductive health (SHR) related problems (Setting et al 2013). As
a result, most of them are not adequately equipped to make informed and responsible decisions. This lack
of information could increase their engagement in risky sexual practices such as early sexual initiation,
having multiple sexual partners, inconsistent or non-use of condoms and low use of other contraceptives.
The study also indicated that young people’s SRH information and service utilization are very low, which
may contribute to the existing burden of SRH problems among this age group.
Ethiopia School Health Program Framework 22

Early sexual debut and sexual activity before age of 18 years is common in Ethiopia. According to the
EDHS 2011, among women age 25 to 49 years, 29% had their first sexual encounter before age 15 and
62% before age 18. The median age at first sexual intercourse for women age 25 to 49 years is 16.6 years,
which is very close to the median age at first marriage (16.5 years). A study at five public universities in
Ethiopia in 2011, reported that more than 30% of the 5,000 interviewed students had started sexual
intercourse before they joined university and the mean age at first encounter was 16.7 ± 2.7 years. A more
specific analysis of Hawassa University showed that about 68% and 12% started sexual practices while
they were in high school and primary school, respectively (Berhan Y et al 2012).

Students also responded that they were engaged in unsafe sexual practice such as having multiple sexual
partners (31%), unprotected sex (sex without condom with non-regular partners) (27%), sex with
commercial sex workers, and non-consistent and improper use of condoms. About 34% of childbirths
among young women aged 15 to19 years were unintended, which result undesirable health outcomes such
as obstructed labor, obstetric fistula, chronic pelvic pain and depression (Tebekaw Y et al 2014).

Another study conducted in Bahir Dar suggested that barriers in utilizing RH services are related to
inconvenient working hours and fear of being seen by parents or people whom they know. Students
between ages 20 and 24 are 2.31 times more likely to utilize RH services than students’ age 15 to 19
years. Similarly, students who had RH related problems are 1.54 times more likely to utilize services than
students who had no reproductive illness. According to EDHS 2011, the highest unmet need for family
planning is among the adolescent age group (15 to19 years). This shows that there is limited access to RH
services that meet the diverse needs of adolescents.

3.7. HIV and sexually transmitted infections

The prevalence of HIV among adolescents and youth in Ethiopia is 1.22%, with significant variation
between young females and males (EPHI 2015). Studies on sexual practices of adolescents and youth in
Ethiopia show that a significant number of young people practice unsafe sex. Initiation of first sex by
Ethiopian youth is around 16-years-old for both boys and girls, however some studies indicate the sexual
initiation for girls can be 6 to 7 years earlier than boys (MOE and FHAPCO 2013).

A research review on youth in Ethiopia documented that 49.7% are sexually active; and more than half of
those youth reported having two or more sexual partners. A study among high school students in
northwest Ethiopia indicated that while most students were well informed about the major modes of HIV
transmission, 39% reported having unprotected sex (sex without condom); and 43.3% of sexually active
students had more than one sexual partner (Attwelly 2004). A study conducted among five universities
also indicated that on average around 30% of university students, both male and female, were sexually
active. In both cases, unprotected sexual practice patterns among students lags behind knowledge and
attitude towards prevention of STIs and condom use. Students suffer from complications of unsafe sex
such as STIs and abortions (Desalegn et al 2011).

A review of the Ethiopian Higher Education Institutions HIV and SRH Package shows that students’ SRH
receive little attention in higher education institutions. When SRH care is available, many students do not
know where to go or are unable to pay for it. Furthermore, available services are not youth friendly.
Universities focus on academic and administrative issues and pay less attention to HIV and SRH. Health
Ethiopia School Health Program Framework 23

service providers also impose age restrictions on providing family planning methods, including condoms,
even when such restrictions are neither medically justifiable nor officially sanctioned.

Researchers also indicate that most sexually risky behaviors among adolescents and youth are related to
engaging in exploratory behavior, unprotected sex, inconsistent condom use, peers’ social approval, false
sense of non-vulnerability, use of substances, misuse of technology for pornographic products, etc. In
addition to these individual risk factors, other structural socio-demographic factors exacerbate young
people’s vulnerability including gender inequality, poverty, and place of residence, HTPs, labor abuse and
lack of adequate infrastructure (Nigatu R & Seman K 2011).

3.8. Mental, neurological & substance use disorder

According to the WHO definition, mental health is “a state of well-being in which the individual realizes
his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is
able to make a contribution to his or her community”. It should be noted that the definition does not refer
exclusively to the absence of “mental illness”, but also addresses the concept of “mental wellness”.
Identifying and preventing MNS and related problems in children, adolescents, and young adults is
critical to ensuring behavioral and physical health. Behaviors and symptoms that signal the development
of a behavioral disorder often manifest two to four years before a disorder is diagnosed. In addition,
people with a mental health issue are more likely to use alcohol or drugs than those not affected by a
mental illness. The lack of attention to the mental health of children and adolescents may lead to mental
disorders with lifelong consequences, undermine compliance with health regimens, and reduce the
capacity of societies to be safe and productive.

Globally, it is estimated that about 10 to 20% of children and adolescents suffer from mental illnesses.
Nevertheless, most young people’s psychosocial problems related to socio-cultural and economic factors
can be addressed through promotion and prevention services. Evidence indicates that about 75% of
mental disorders in adulthood have their onset in youth, particularly in the 12 to 24 year age group. A
systematic review conducted in 2012 to determine rates of psychopathology in children and adolescents in
SSA reported an overall prevalence of 14.5% for children up to age 16 years. Additional studies from
Kenya and South Africa reported prevalence of 10.8% and 34.9%, respectively.

In Ethiopia, mental illness in children and adolescents is estimated to be between 17% and 23%, with
lower prevalence in rural settings. A cross-sectional study undertaken in Butajira (Southern Ethiopia)
indicated that 3.5% of study participants had at least one or more mental and behavioral disorders, among
which anxiety disorders (1.6%) was the most frequent followed by attention deficit hypersensitive
disorder (1.5%), disruptive behavior disorders (1.5%), mood disorders (1%) and elimination disorders
(0.8%). The most significant risk factors for the development of psychopathology in children and
adolescents are related to socioeconomic problems. These include maternal psychopathology, disruption
of the family and marital status, exposure to stressful events, and poverty related factors (such as
insufficient food, low socioeconomic status, and illness). The GoE has undertaken several measures to
address mental health problems. In 2010, a survey of psychiatric problems in children and adolescents in
Ethiopia revealed schizophrenia, bipolar disorder, depression, suicidal attempt, alcohol abuse and
cannabis use/abuse as major psychiatric problems.
Ethiopia School Health Program Framework 24

In 2012, MoH developed a Mental Health Strategic Plan for 2012/13 to 2015/16 with an aim to address
the mental health needs of all Ethiopians through quality, culturally competent, evidence-based, equitable
and cost-effective care. In this plan, particular attention was given to the special needs of particular
vulnerable populations including children and adolescents. The National Initiative for Mental Health in
Ethiopia (NIMHE) was established in 2005 to guide the overall development of national mental health in
Ethiopia focusing on child and adolescent mental illness. Mental health services in schools should be
comprehensive and continue to focus on promoting healthy development and address barriers to
development, learning, parenting and teaching. The services should also address issues such as school
adjustment and attendance problems, dropouts, physical and sexual abuse, substance use disorder,
relationship difficulties, emotional upset, delinquency and violence.

The forms of violence found in schools can be physical, sexual and emotional, and can occur together.
Violence perpetrated by teachers and other school staff include corporal punishment and other cruel and
humiliating forms of punishment or treatment and sexual and gender-based violence. Violence
perpetrated by children includes bullying, sexual and dating violence, schoolyard fighting, gang violence
and assaults with weapons (United Nations 2006). Such incidences are often not reported and active
tracing of survivors needs to be undertaken by health workers in close consultation with school teachers.

Use of narcotic or psychotropic substances affects an individual’s health and psychosocial behaviors. Use
of substances such as khat, tobacco and alcohol is widespread among adolescents and youth in Ethiopia.
The 2011 EDHS report indicated that 45.6% of Ethiopian adolescents and youth consume alcohol more
than six times in a month with higher rates in males (47.7%) than females (43.5%). Recently, the national
prevalence of khat consumption among adolescents and youth is 51%, again with higher rates among
males (56.5%) than females (36.6%) (CSA ORC Macro 2011). Furthermore, khat chewing is presumed to
increase the prevalence of smoking cigarettes, Shisha, hashish and other highly addictive drugs. A study
in Bahir Dar University students revealed that lifetime prevalence of khat chewing was 24% of which
12.7% were current users.

3.9. Non-communicable diseases and injuries

Non-communicable diseases (NCDs) are the leading causes of death globally, killing more people each
year than all other causes combined. Of the 56 million deaths that occurred globally in 2012, 38 million
(68%) were due to non-communicable diseases, comprising mainly cardiovascular diseases, cancers,
diabetes and chronic lung diseases. Contrary to a widely held opinion, available data demonstrates that
nearly 85% of deaths due to NCDs occur in low- and middle-income countries. The main causes of NCDs
are known. A set of common risk factors are responsible for most of the major NCDs including unhealthy
diet, physical inactivity, harmful use of alcohol and tobacco use. Elimination of modifiable risk factors
would prevent 80% of premature heart disease, 80% of premature stroke, 80% of type 2 diabetes and 40%
of cancer.

In Ethiopia, khat use and indoor air pollution are additionally considered as important risk factors for
NCDs. Khat is included as a risk factor because of the vicious cycle between khat chewing and other
major NCD risk factors. While chewing khat, individuals concomitantly consume high levels of tea,
sugary carbonated drinks and coffee and the ceremony is often accompanied by cigarette smoking. The
WHO estimates that in Ethiopia 30% of deaths in 2012 were due to NCDs in the year, of which cardio-
Ethiopia School Health Program Framework 25

vascular diseases accounted for 9%, cancer for 6%, chronic obstructive pulmonary diseases for 3% and
diabetes mellitus for 1%. In addition, other various NCDs contributed 11% of mortality and injuries an
additional 9%. Communicable, maternal, perinatal and nutritional conditions accounted for 60% of the
deaths in the same year. The Ethiopian National STEPS Survey on NCDs conducted in 2015/16 among
adults aged 15 - 69 years showed 4.2% as current smokers and nearly 41% had consumed alcohol during
the past 30 days prior to the survey.

A total of 60.4% of respondents responded that they always or often add salt or salty sauce to their food
before eating or as they are eating. About six percent of the study population did not meet WHO
recommendations on physical activity for health and among those who reported physical activity 21.8%
were in the low level of activity group and about 16% of respondents were current khat chewers.
Regarding injury, about 3% of respondents were involved in a road traffic crash as a passenger, driver, or
pedestrian during the past 12 months preceding the survey. About 3% of respondents had been seriously
injured in a non-road traffic-accident (commonly falls, cuts and animal bites) in the past 12 months. In the
past 12 months, 1.5% of respondents were involved in violent injury. Almost 2% of the respondents were
sexually abused during adulthood. In the same study, prevalence of raised blood pressure (SBP > 140
and/or DBP > 90 mmHg) among Ethiopian adult population was 16%, 6.4% were overweight or obese
and 21.6% were underweight. From the study participants, 6% had raised blood glucose or diabetes.
Rheumatic heart disease which occurs following streptococcal tonsilopharyngitis is also a major cause of
cardiovascular morbidity and mortality in children and young adults in Ethiopia as shown by recent
studies at hospital level, in schools and at the community level.

Cancers are also common medical problems in Ethiopia. Breast and cervical cancer are leading causes of
cancer in women while prostate cancer, colorectal cancer and hematologic cancers are the leading causes
of cancer among men. Studies in Addis Ababa and Gondar show the prevalence of chronic respiratory
diseases, such as asthma, in children and adolescents is 2.8% and 3.8%, respectively.

Unfortunately, there is a common misconception that NCDs do not affect children, but are diseases of
adulthood only. However, evidence shows that NCDs and their risk factors have enormous impact on the
health of children. Children suffer from a wide range of NCDs; some are triggered in childhood by
complex interactions between the child’s body, surrounding environment, living conditions, infectious
agents, nutritional and/or other factors. There is a rise globally in overweight and obese children and
children with type 2 diabetes. Globally, nearly 22 million children under 5 years of age are overweight.
Overweight and obese children are likely to stay obese in adulthood and more likely to develop NCDs
like diabetes and cardiovascular diseases at a younger age. The overall prevalence of overweight/obesity
ranged from 5.9% to 17% in studies on children and adolescents from Ethiopia. The prevalence of current
and lifetime smoking varied between 1.8% - 28% and 5.8% - 22.8%, respectively among adolescents
and young adults in studies among these age groups. Effective interventions are available and urgent
action is required.

Injuries are the other important health problems affecting children and adolescents. The young age of
schoolchildren, the stage of their development and the manner with which they interact with the world
make children especially susceptible to injuries. Injury prevalence is highly associated with age and stage
of development. According to the World Health Organization Global Health Estimates (GHE 2014),
injuries caused 5.14 million deaths globally and of those, 372,512 were in children under than 5 years and
Ethiopia School Health Program Framework 26

367,540 among children aged 5-14 years. Child injuries are a serious public health problem and
unintentional injuries are among the top causes of child mortality in Ethiopia. According to GHE 2014 of
the 68,948 total injury deaths in 2012 G.C. in Ethiopia, 13,002 deaths were among children under 5 years
and 9,267 among children 5 - 14 years old. These are likely underestimates as many injured or disable
children do not access formal care.

3.10. School health during education in emergency

Ethiopia is vulnerable to both natural and human made emergencies such as drought, floods, heavy winds,
storms, landslides and armed conflicts. In 2015, Ethiopia experienced the worst drought in 50 years. The
delay of rain fall and its erratic nature resulted in failure of major crop production and greatly affected
livestock population and the livelihood of 5.6 million people. In 2016 the number affected has increased
to 7.8 million people. It seems that emergency is becoming a recurrent phenomenon.

The education sector is one of the emergency affected sectors. A review of emergency responses
implemented from 2010 to 2014 shows that the number of school age children affected by emergencies
averages 250,000 annually. About 2.1 million school age children were affected in 2015. This has grown
to 2.8 million in 2017. According to the Meher Assessment findings, affected schools are experiencing
closures and quite a number of school children are experiencing absenteeism and gradually dropping out
with the main drivers being shortage of nutrition/school feeding, water and health services which can be
addressed by a SHP. About 90% of Education in Emergency (EiE) responses have been provided by the
government particularly in terms of school feeding and school WASH. However, there is a fear that
Ethiopia’s past gains in achieving the Millennium Development Goals (MDGs) may be lost in the
Sustainable Development Goals (SDGs) due to the growing number of emergency situations if EiE is not
given serious attention and addressed through a pragmatic approach to incorporate EiE in school health
and related programs.

4. SLOT analysis
The overall strengths, limitations, opportunities and threats (SLOT) analysis in implementing the SHP
were assessed during a round table discussion among experts from partners and stakeholders as well as
brief school visits by the team to explore the existing situation. The figure below summarizes the
consensus reached on the review of the SLOT analysis for the SHP.

F IGURE 3 SLOT ANALYSIS FOR SHP

Strengths Limitations
• Government and ministerial goodwill • Nonexistent or limited health services in
• Increasing number of schools, pre-schools schools/universities
TVETs and universities • Infrastructure and space limitations in schools (Class
• High school enrollment rate rooms, toilets, clean water, playground)
• Increasing number of teachers and other staff • High turnover of teachers and other staff
• Existence of the SHN strategy by MoE • Mixed attitude at school for some package components
Ethiopia School Health Program Framework 27

• Increasing primary health service coverage • Low health literacy level of teachers and students
• Strong community health program • Weak linkage and referral between schools and health
• Availability of national strategies and guidelines facilities
on childhood, adolescent and youth health • Weak student engagement in the program
(AYH) strategy (2016-2020) • Underdeveloped health insurance
Opportunities Threats
• Favorable global momentum on childhood, • Unpredictable local and international funding
adolescent and youth health through SDGs • Urbanization and globalization
• Economic growth • Growing young population
• Increasing health seeking behavior • Climate change
• Urbanization and globalization • Suboptimal multi-sectoral collaboration and
• High infrastructure and communication coordination
technology development (Mobile, FM) • Increasing access to unhealthy foods and drinks
• Existence of Education Development Army • School closure time missed opportunities due to
(EDA) seasonality of school calendar

5. Rationale
The period of rapid growth and development that occurs in childhood has a profound impact on future
health outcomes and the quality of life enjoyed in adulthood. It therefore represents a window of
opportunity in terms of improving the overall lifetime health of populations and promoting the right to
health for all. About 70% of adulthood diseases and health conditions are the result of health behaviors
during adolescence and young age.

If comprehensive intervention strategies are not adequately designed and implemented, children and
adolescents are prone to disease burden. A focus on children that promotes generational and population
based change is needed. Children can be powerful health agents and peer educators for positive change.

In Ethiopia, over 37 million people are enrolled at various levels of the education system, which provides
a unique opportunity to reach nearly one third of the Ethiopian population through school based health
interventions. The existing school based health initiatives lack an evidence-based approach for the
systematic integration of health including nutrition information and services within the education
structure at all levels. In addition, different school based health interventions such as HEP, WASH, HIV,
nutrition and youth friendly services have been implemented in vertical approaches. More importantly,
the existing interventions do not address the needs of most fragile and critical populations of pre-primary
students (age group 4 - 6 years) and students of primary schools (age group 5 - 10 years). Adolescent
students also do not get necessary services for MHM as well as sexual and reproductive health education.

In order to narrow the gap and to expand health services in an equitable manner, the MoH and
stakeholders see the need for a comprehensive SHP with essential health services tailored to students at
different levels in order to create health promoting schools as a means to alleviate current health problems
and promote generational and population-based positive change. The school health packages proposed
under this new program are therefore intended to provide evidence-based, standardized and
Ethiopia School Health Program Framework 28

comprehensive school based health information services and referral to all Ethiopian students from pre-
school to tertiary educational levels of education.

6. Strategic framework
6.1. SHP objectives
General objective: To improve health and well-being of students and enable them to be health change
agents in their communities by providing a comprehensive SHP.

Specific objectives
To improve the knowledge, values and attitudes of students in order to make and act on the most
appropriate and positive decisions for health.
To produce a ‘health conscious’ generation through formal and informal education and practice.
To help early detection of diseases through routine screening.
To enable students to be health change agents for their families and the community at large.
To contribute to student retention in schools and increase their education efficiency.
To promote convenient and healthy school environment.

6.2. Scope of the SHP and alignment with existing strategies

The SHP Framework is intended to encompass all available health services including promotive,
preventive and curative services for students from the pre-school to college and university level across all
types of schools irrespective of their ownership (i.e. private, community and government owned).

The SHP Framework provides the list of service packages by school type (pre-primary, primary,
secondary and tertiary levels) that will be delivered using school health centers. It also outlines inputs,
processes and monitoring and evaluation requirements at each level of schools.

This proposed program, however, will strongly support already functioning programs such as HEP
(Health Extension Program), school feeding program, school WASH program, etc.

6.3. Guiding Principles of the SHP Framework

Right-based: Students have the right to obtain comprehensive health services in an appropriate and
convenient place.

Equity and inclusion: The package guides SHPs to recognize and address the needs of students of
different age levels and both genders in an equitable, non-discriminatory manner that is free from
stereotyping. For those students with special needs the existing system and infrastructure will be utilized
to address their health needs.
Ethiopia School Health Program Framework 29

Life-course approach: Efforts are targeted to break or disrupt negative intergenerational cycles that are
created by or contribute to health inequities. Students in turn will create the condition for healthy future
generations as parents, grandparents and caregivers.

Comprehensive care: Comprehensive means not only that care responds to the full range of health
problems, but also that care for any condition encompasses, health promotion and prevention, diagnosis
and treatment or referral (WHO 2015).

Student friendly services: An approach to care that consciously adopts the perspectives of individuals,
families and communities, and sees them as participants as well as beneficiaries of trusted health systems
that respond to their needs and preferences in humane and holistic ways. It requires that people should
have the education and support they need to make decisions and participate in their own care.

Integration: Integration of student health care services is emphasized. Focus is on integration of student
health care services within the existing primary and referral care systems, the systematic integration of
basic student health care service indicators in regular information systems, and coordination and
implementation through the integration of actions and strategic areas at all levels.

Innovations: There is a focus on the wide use of interactive media and technologies for SBCC and as
means of service delivery. More investment will be made for testing and scaling up of new technologies,
products and theories/models to increase access, utilization and coverage of services.

Compassionate, respectful and competent human resource: Focus on compassionate, respectful

and competent health care service by ensuring adequate skill mix of human resources at school and at all
levels of the health system. Care, empathy, trust, and enabling environment for informed decision making
characterize the relation between service providers and their clients.

6.4. Strategic Principles and Approach

The strategy to be followed promotes a unified definition of a comprehensive and inclusive SHP, one that
reflects the following principles:

A child-centered and child-friendly approach means a strengthened focus on the well-being of

children; identifying, and responding to their individual health needs of medical treatment, psychological,
and special aid and support.

Increased focus on prevention of diseases and protection of health and well-being by

addressing health risk behaviours through skills based health education, as well as recognizing and
addressing social and environmental barriers that affect students’ health and wellbeing.

Service delivery will be integrated with tailored delivery of promotive, preventive including regular
screening, curative and rehabilitative services. On-site (static), outreach, and mobile forms of service
delivery will be used. Integrated and age appropriate information, education and services that can meet
the exact need of children at school will be provided. Promotion of healthy lifestyles and behaviour
change that protect children from harmful behaviour and practices will be included. The curative services
will focus on common communicable and non-communicable disease such as skin diseases; mild
respiratory infections, injury, first aid care and other diseases are addressed. Children affected by diseases
Ethiopia School Health Program Framework 30

or nutritional problems or addiction problems will receive additional follow up and care. The service
delivery of school healthcare will occur during working hours of the schooling. For those students with
special needs the existing system and infrastructure will be utilized to address their health needs.

Ownership by school management and staff requires that school health is an integral part of school
plans and ongoing activities and that all teachers and school administrative bodies at different levels take
responsibility for health education, students’ health and well-being.

Parental and community engagement, together with the school health team and teachers, will be
encouraged in order to share information on the health needs of their children to take an active role on
needed actions and support.

Capacity building of teachers and counsellors will be strengthened at school to ensure ownership and
sustainability of SHPs.

Referral network and linkages will be formed between schools and health facilities along all tiers.

Inter-sectorial collaboration as MoE and MoH will play a central role in communication and
information sharing, joint planning and implementation of school health activities and must be flexible
and responsive in order to react and follow up to health needs of students. Since school health is not the
responsibility of one single sector, the establishment of an institutional framework, along with
collaboration and networking, advocacy and resource mobilization, and monitoring and evaluation will
govern the overall work at all levels of program implementation.

6.5. Conceptual framework and logical score card

Figure 4 highlights the concepts used to develop the Ethiopian School Health Program and guides
selection of interventions appropriate for the priority health problems among children and adolescents in
schools. Table 1 is the logical scorecard developed to monitor and evaluate the implementation of the
SHP.
Ethiopia School Health Program Framework 31

F IGURE 4 SHP CONCEPTUAL F RAMEWORK

Impacts Healthy
confident
,
productive
citizens

Outcomes 1. Students as change agents

2. Minimized educational wastage

3. Safe and healthy school environments

SH Service packages 1. SBCC and Life skill training 6. SRH

2. Nutrition 7. HIV/STIs
3. WASH 8. MNS disorders
4. Mgt of common disorders 9. NCDs & injuries
5. Vaccination 10.Emergencies in schools

Strategic Ownership by Parental and Referral

approach Capacity school community network and Inter sectorial
building management engagement linkage collaboration

Student health problems (nutrition, WASH, communicable and non-communicable diseases)

Ethiopia School Health Program Framework 32

TABLE 1 SHP LOGICAL S CORECARD

Results-Chains Performance Indicators/Sources of Verification

Impacts From Year 2017- 2020
Healthy, confident, productive and competent citizen IV1: Improvement of health status of the school age citizen
Outcomes (Mission)
Increased students efficiency and effectiveness OM1-1: measure of educational achievements
Safe and healthy school environment creating health conscious and OM1-2: Percentage of school that are environment and child
Change agent students for themselves, families and communities. friendly
OMI-3: Percentage of students who are health conscious
OMI-4: Percentage of schools insured health seeking behavior
of students
Outputs (Deliverables)
OUT-1: {Hardware}: Access to School-based Health Centers with OD1-1: 38,023 school Health centers functional by 2020
adequate space, supplies including medical drugs and clinical OD1-2: Approved manuals in place in all school health centers
equipment, printed manuals /guidelines for Health Packages by ODI-3: Percentage of schools having access to sanitation
2020. facilities
ODI-4: Percentage of schools having access to water facility
ODI-5: Percentage of schools received nutritional assessment
ODI-6: Percentage of schools received mass deworming
OUT-2: {Software}: Curriculum for the SHP in place PLUS OD2-1: The curriculum for SHP in place by 2020
school health promotion conducted through clubs, health workers OD2-2: Percentage of schools provide regular school health
and other methods on a regular basis by 2020. education as the program required
OUT-3: {Human resource}: Teachers, school health workers, OD3-1: Percentage of schools having functional school health
administrators, PLUS students at all educational levels trained in clubs
'positive health seeking behavior’ and supported to use their OD3-2: Percentage of schools received training on school
knowledge and skills by 2020. health for teachers, school health workers, and school
administrators.

OUT-4: {Management}: The SHP is efficiently and effectively OD4: Project managed within budgets and plans.
managed by 2020.
Ethiopia School Health Program Framework 33

Activities (Processes)
Act-1: {Hardware}: Design, plan and build or identify and designate spaces for school-based health centers PLUS write
guidelines/training manuals for the SHP
Act-2: {Software}: Review, develop and update existing curricula of schools PLUS rules, regulations, procedures, methods for
delivering the Health Packages (i.e., information, services and referral).
Act-3: {Capacity building}: Design, plan, and implement a comprehensive capacity building initiative for the SHP.
Act-4: {Management}: Undertake key functions pertaining to planning, achieving and learning including annual work planning,
mobilization of team members, agreement on roles and responsibilities (HR), effective internal and external communication,
mobilization and management of funds, and effective supportive supervision, and Monitoring and Evaluation.
Inputs / Resources for:
Essential infrastructure, facilities, materials and supplies and human resource
Ethiopia School Health Program Framework 34

7. SHP Packages
The MoH and relevant stakeholders shall ensure that health issues be included in the school curriculum
and be taught as subjects in all schools. They shall also make sure that updates to the health related topics
occur based on revisions to national health strategy. The MoH shall also facilitate and support provision
of health services in schools such as counseling and social services, visits by nurse/doctor and linkages to
the referral system for the package of interventions described below. The intervention packages are areas
where schools shall provide a comprehensive and holistic health and support services to students with a
focus on health education, health services, social support and physical environments in order to meet the
health and health related needs of students within the school. The packages are broadly grouped as
follows:
1. Social and behavioral change communication and life skills development
2. School nutrition services
3. Water, sanitation and hygiene (WASH) provision
4. Management of common infections, infestations and disorders
5. Routine and catch-up vaccination and immunization service
6. Sexual and reproductive health services
7. HIV/STI prevention and control services
8. Mental, neurological and substance use disorder prevention and support
9. Prevention and management of non-communicable diseases and injuries
10. School health preparedness, response & recovery during education in emergency

Package 1: Social and Behavioral Change Communication (SBCC)

and life skills development
Health education is a combination of learning experiences designed to help school communities and
parents improve their health by increasing their knowledge, skills and attitudes. Knowledge alone does
not necessarily foster appropriate health habits. To facilitate effective decision making in health matters,
the school system should provide every child with the opportunity to acquire knowledge and skills
essential for understanding healthy functions, develop attitudes and habits that promote a healthy lifestyle,
and practice health skills conducive to effective learning and living.

SBCC can be provided through direct teaching, use of mini-media and school health clubs, printed
materials (e.g., flyers, stickers, posters), audio and audiovisual materials (e.g., documentary films,
dramas, feature stories, spots, and news stories), entertainment programs, e-learning (e.g., social media,
blogs), peer learning, life skill learning, youth dialogue, guidance and counseling, panel discussions,
health-related questions and answers and round table discussions.

Life skills allow for the development of adaptive and positive health behaviors that enable individuals to
deal with demands and challenges of life. They are essential for promotion of health and wellbeing of
children and adolescents. Life skills development activities in schools encompass the most important
skills a person needs to have during young and adult life. These skills include decision making, problem
solving, creative thinking, critical thinking, communication, relationship building, self-awareness,
empathy, coping with emotions and stress management.
Ethiopia School Health Program Framework 35

The life skill training should also emphasize the prevention of harmful traditional practices (HTP)
including prevention of early marriage, which affects the lives of many adolescent girls in Ethiopia. This
package will promote skills that ensure adolescent girls are enable to exercise their full and
comprehensive sexual and reproductive health rights, including the right to choose when and whom to
marry and how many children they want to have without peer and community influence.

The activities for life skills development for school children includes in-school activities such as class
discussion, brain storming, role play, educational game and simulations, case stories, storytelling, debate
and school linked programs and out-of-school activities, such as campaigns to promote community
interventions and social norms.

Package 2: School Nutrition Services

This package encompasses activities for school feeding, school gardening, micronutrient
supplementation, nutritional status assessment, counseling, support and referral. Good nutrition is
required for optimal health and physical and intellectual development. School feeding services will be
provided to pre-primary and primary school children in schools as part of SHN program as school meals
attract learners into schools and relive short-term hunger that slows the learning process. The package
also provides nutritional support for severely malnourished students and those with special needs. School
feeding programs, which are already in place in drought affected and food insecure urban areas of the
country, help to create an enabling environment and are well equipped to drive and support other
interventions on education, health, nutrition/ hunger and sanitation. The existing school feeding programs
also will serve as spring board and good platform to act and prevent nutritional related health problems.

The package includes supplementation of micronutrients to prevent deficiencies. Establishing school

gardens, promoting homestead gardening in order to increase food diversification, cooking
demonstrations and provision of skills in basics of food safety are also part of the package. The package
will be delivered to children and adolescents through nutritionists and trained health professionals, food
experts and post-harvest and agriculturists or trained teachers.

Nutritional status assessment, counseling and support to be provided include:

Screening for macro- and micro-nutritional status;

Macronutrient under nutrition in children (Stunted, wasted, underweight/stunted-wasted)
Macronutrient over nutrition in children (overweight, obesity)
Micronutrient under nutrition/deficiency (e.g., iron, vitamin A, zinc, iodine, vitamin D)
Assessment of dietary adequacy, quality and safety;
Counseling on healthy dieting and life style;
Teaching students on the detrimental and long consequence of malnutrition;
Providing educational materials that reinforce messages about healthy eating and skills on
essentials of dietary planning;
Supplementation of micronutrients;
Linking students with acute macronutrient deficiency/acute malnutrition to feeding centers.
Ethiopia School Health Program Framework 36

Package 3: Water, Sanitation and Hygiene (WASH)

This package focuses on ensuring the availability of an inclusive, adequate, and potable water supply,
gender segregated improved latrines and hygiene facilities and proper solid and liquid waste management
at all schools. It also focuses on the development of clean, safe and well-ventilated classrooms and
playgrounds for outdoor sports and physical activities. Schools are often a place where children become
ill as the physical environment and cleanliness of a school facility significantly affects the health and
well-being of children. Disease can spread quickly in crowded spaces with limited classroom ventilation
and unsafe school environments where hand-washing facilities, detergents, and toilets are unavailable.

The provision of a WASH package compliments national and local interventions to establish equitable,
sustainable access to safe water and basic sanitation services in schools. Poor sanitation, water scarcity,
inferior water quality and inappropriate hygiene behavior contribute to the health and well-being of
school-aged children who spend long hours in schools. The WASH package at the school level advocates
for evidence-based WASH knowledge management through the engagement of the MoE regarding the
existence, benefits and conditions of WASH structures at schools.

Provision of an adequate supply of clean water for cleaning, washing and drinking at schools plays a
pivotal role in prevention of common communicable diseases and reduces water borne diseases. Hence
this package considers the availability, quality, adequacy and continuity of clean water, toilet facilities
and waste disposal systems to help make the school environment free of foul smell and disease-causing
pathogens.

This package also encompasses mechanisms to control for fire, electrical and other accidents and injuries
with full first aid services available to prevent and control accidents.

Package 4: Management of common infections, infestations and

disorders
The intention of this package is to help school children prevent and manage curable diaseases and
disorders through the evaluation, diagnosis and treatment of diseases. Delivery of onsite evaluation and
curative services for common infections, infestations and disorders in children and youths is an important
package in the SHP. Although there is no limitation to screening, treating or referring of any medical
problems affecting children in schools, special emphasis will be given to the detection and intervention of
thecommon health problems of children and youths outlined below:
Fungal and bacterial skin infections,
Skin infestations (Sarcoptes scabie, Myiasis, chiggers, dust mites, lice),
Intestinal worm infestations,
Eye (trachoma) and ear (otitis media and externa) infections,
Visual defect (refractory errors) and hearing defect,
Upper respiratory tract infections (URTIs),
Sexually transmitted diseases (STDs),
Dental caries and periodontitis,
Physical disabilities and accidents.
Ethiopia School Health Program Framework 37

Training of the the health service providers in the school health centers will focus on these common
problems.

Children are more susceptible to worm infection due to the fact that children’s behaviors make them
vulnerable to oral-fecal or soil-to-skin contact. Such infections have negative effects on growth,
nutritional status, physical activity, cognitive development, mental concentration, and school
performance. Adolescent girls are at risk of anemia, aggravated by parasitic infections. Schools are an
ideal place to conduct periodic assessment and treatment to control these diseases. Periodic school-based
mass deworming is one of the most cost effective interventions in child health. Therefore, this package
focuses on conducting periodic mass deworming campaigns at schools using common anthelmintic drugs
in order to improve student health and academic performance.

The intention of the package is to improve the health of school children, including those with special
needs, by providing timely evaluation and treatment of diseases and disorders. Therefore, other infections
and disorders, as listed above, will be diagnosed and treated at the school health center, or in the case of
more severe cases, be referred for further evaluation and definitive treatment to health centers. This
package compliments preventative and curative services rendered at the primary health care level. The
school community needs to be vigilant in the handling minor injuries and, in the rare instance, occurrence
of major accidents; therefore, the school health center will be equipped with first aid instruments to
provide for the emergency management of injuries, including splinting, open wound care and suturing
.The services will be provided by skilled health professionals in collaboration with the school
administration.

Package 5: Routine and catch-up provision of vaccinations and

immunizations
The school can serve as a service delivery point for providing booster doses and other nationally
recommended childhood and adolescent vaccinations. Teachers and school authorities should ensure that
all pre-school children are fully immunized for their age before enrollment. Children who are not fully
immunized per national guidelines for their age group will be referred to the school health facility for
their missed vaccinations.

The health center at the school needs to ensure that there is at least one health education session per
academic year focused on vaccine-preventable diseases and immunization. As the school enrollment rate
is now at 94%, schools will be used as the primary venue for immunization campaigns when new
vaccines are introduced. The new national immunization schedule, which includes TT/Td immunization
for girls and boys in first cycle primary school and human papilloma virus (HPV) vaccines for girls 9 to
14 years of age, will be implemented using schools as the delivery point. Per the new immunization
schedule all girls age 9-14, regardless of school enrollment, will be vaccinated for HPV, as early as in
2017 (G.C.) or immediately thereafter. For operational purposes, grade 3 up to grade 8 will be considered
for initial multi-year targets; and after the first year of vaccine introduction, the routine cohort schedule
will target 9 year old girls in grade 3. Based on the epidemiology of the diseases and launch schedules,
students in school will be targeted in the coming years for the hepatitis B virus vaccine, the meningitis A
vaccine, the second-dose of measles vaccine and the measles-rubella vaccine.
Ethiopia School Health Program Framework 38

During supplemental immunization activities, school-based health facilities and school authorities shall
ensure that all students in their schools have obtained potent and valid doses of the supplemental and
catch-up vaccinations. The catch up vaccination program will provide an opportunity to administer
vaccines missed during infancy. These school-based facilities also will support the planning, registration
and reporting of vaccination coverage in their schools to the health authority.

Package 6: Sexual and reproductive health (SRH) services

Access to SRH services is a primary concern of adolescent and youth due to the sensitive nature and risk
of sex and sexuality issues. In this package, age appropriate SRH information and education will be
provided at each level of school. The provision of SRH services will be comprehensive and rights-based.
Comprehensive SRH rights state that services should be voluntary, informed and affordable.

The major focus of the SRH package will occur in the 2nd cycle education and will focus on sexual health
education and health behavior promotion, including information on delaying and abstaining sexual
activity. The package will also provide for the management of menstrual disorders, diagnosis and
treatment of common STIs and HIV counseling. At the secondary school level, students seeking HIV
testing and sexually active students seeking contraceptive services like condoms, oral contraceptives
(including emergency contraception), injectables, and implants will be referred to the nearby health
facility. At the tertiary level of education, HIV counseling and testing and all types of contraceptive
services, including intrauterine device (IUCD) insertion will be provided. In addition, as per the rule of
the country, comprehensive abortion care services will be provided for students who encounter
unintended pregnancy. Counseling, treatment and referral services to address gender based violence,
either physical or sexual, will be provided at all levels of education. Depending on the level of the school
health care center, trained nurses, health officers or general practitioners will provide the youth friendly
SRH services.

Package 7: HIV/STI prevention and control services

Effective HIV and STI programming focuses on the critical relationship between the epidemiology of
HIV and STI infections, the risks associated with the infections, and the cultural, institutional and
structural factors that drive those risk factors. Risk behaviors are entangled in a complex web of
economic, legal, political, cultural and psychosocial determinants that must be analyzed and addressed by
polices that are also effectively implemented and scaled-up. Efforts targeted to prevent and reduce HIV
and STI infections for youth will primarily focus on measures that directly support age-appropriate risk
reduction by providing information and developing skills, as well as provide access to services and
commodities like condoms, IEC materials, and voluntary counseling and testing (VCT) for the school-
aged population. The SHP HIV/STI package addresses the collective social and institutional factors such
as sexual norms, gender inequality, and stigma related to sexual behaviors that will otherwise continue to
contribute to HIV and STI infections.

This HIV/STI package helps not only to understand risk factors but also enables students to adopt safer
behaviors, understand why they engage in risky behaviors, motivate them to reduce their risk, develop
their knowledge and skills and improve their access to means of protecting themselves in a friendly and
supportive way. HIV care and treatment services provided to students are susceptible to stigma and
Ethiopia School Health Program Framework 39

discrimination, confidentiality, consent and assent issues. Thus, the services should be provided according
to national HIV testing and counseling guidelines. The health care and behavior change communication
services of the HIV/STI package will be designed to be age-appropriate across the primary, secondary and
tertiary education levels.

Package 8: Mental, neurological and substance use (MNS) disorders

prevention and support
Promoting mental health and preventing MNS disorders is fundamental to reducing the impact of
behavioral health conditions in our communities. MNS disorders can have a powerful effect on the health
of individuals, their families, and their communities.

The main interventions to address psychosocial, mental health, substance use and violence issues in
schools will focus on: ensuring academic success and promoting healthy cognitive, social, and emotional
development and resilience; addressing barriers to student learning and performance including
educational and psychosocial problems, external stressors, and psychological disorders; and providing
social/emotional support for students and staff. The major areas of concern related to barriers to student
learning in relation to mental health include:
Addressing common educational and psychosocial problems (e.g., learning problems; language
difficulties; attention problems; school adjustment and other life transition problems; attendance
problems and dropouts; social, interpersonal, and familial problems; conduct and behavior
problems; delinquency problems; anxiety problems; affect and mood problems; sexual and/or
physical abuse; neglect; substance abuse; and psychological reactions to physical status and
sexual activity).
Countering external stressors (e.g., reactions to objective or perceived stress/demands/
crises/deficits at home, school, and in the neighborhood; inadequate basic resources such as food,
clothing, and a sense of security; inadequate support systems; hostile and violent conditions).
Teaching, serving, and accommodating disorders/disabilities (e.g., learning disabilities; Attention
Deficit Hyperactivity Disorder; school phobia; conduct disorder; depression; suicidal or
homicidal ideation and behavior; post-traumatic stress disorder; anorexia and bulimia; and special
education designated disorders such as emotional disturbance and developmental disabilities).

Package 9: Prevention and control of non-communicable diseases

(NCDs) and injuries
The risk of NCDs may occur at critical periods of human growth and development or risks may
accumulate with age and be influenced by factors acting at all stages of the life span. Thus, prevention
and control of NCDs should target people at all stage of the life span.

Schools can provide an excellent setting to educate students to refrain from risky behaviors and adopt
healthy life styles and to transmit these messages to the larger community. School settings also provide an
opportunity for screening and early detection of certain NCDs in children and adolescents such as heart
diseases, hypertension and diabetes. The SHP will focus on limiting exposure to and use of substances
such as tobacco, alcohol, khat and other drugs and promoting a healthy diet and physical activity.
Ethiopia School Health Program Framework 40

Exposure to khat and to tobacco either by direct use or through second hand smoke is detrimental to the
health of children and adolescents. Every effort should be made in schools to increase awareness of the
hazards of tobacco and khat, to improve life skills to combat commercial and peer pressure, and to
establish schools and universities as tobacco and khat free. Teachers and other staff should not be allowed
to use these substances in the school environment. Additionally, any level of alcohol use is harmful to
physical and mental health of children and adolescents. Hence schools are the ideal places to learn about
harm related to alcohol use and inculcate the idea of alcohol free childhood and youth.

When diseases such as diabetes and cancer occur in children and adolescents, they are a huge burden to
the individual and the family. The individual will be affected by the disease itself and also by the stigma
and discrimination in the school environment. It is imperative that teachers and the school health team
identify children with such medical conditions and increase awareness within the school community
about the conditions and their management. Screening can also be completed for selected NCDs in
schools and universities based on availability of personnel and resources. Rheumatic heart disease,
diabetes, hypertension and cancer screening programs have been completed elsewhere and showed good
outcomes and could be replicated in this context. The promotion of healthy diets and physical activity by
encouraging culturally appropriate, affordable and balanced dietary habits for school children and
adolescents and encouraging activities of daily living and recreational activities, such as walking, cycling
and sport is also be a part of the package to reduce modifiable risk factors for NCDs.

Also part of this package is a focus on injury preventing strategies. Schools at all levels are excellent
outlet in providing injury prevention and control services. Basic principles that underlie most successful
child injury prevention programs in schools include: environmental modification of playground and other
indoor and outdoor facilities; promotion of safety devices (e.g. helmets and seat-belts); development and
implementation of standards for school safety (e.g. zebra crossing and appropriate type and depth of
playground surface material); and health education and life skills development (e.g. first aid and
swimming lessons). Standardization of safety education curricula increases the likelihood that all children
will receive similar information. Table 2 outlines interventions to reduce injuries that should be promoted
in the school environment.

TABLE 2 I NTERVENTIONS TO REDUCE I NJURIES

Goal Interventions recommended
To avoid or minimize road traffic o Engineering: Create safe playing areas and safe roads to school, use
injuries roads with less traffic.
o Education: Targeted messages to particular places in communities
with repeated injury incidents (family, household, daycare centers,
and nursing schools, guardians) to create awareness. Do not leave
children unattended on the streets.
o Legislation: Enforce speed limits, car seats, and substance use,
passenger limit in school buses/minibuses. Import cars with safety
design. Promote not taking children 0-4 years on motorcycles. Explore
use of first aid kits in all schools.
o First aid skills for caregivers, police, teachers, drivers, and fire
fighters. Every vehicle should have first aid kits.
o Establish trauma centers and ambulance systems and link them with
places with repeated injury cases. Trauma centers should be
decentralized and equipped with necessary appliances.
To avoid or minimize falls o Engineering: side railings on roads, railings on windows and beds,
Ethiopia School Health Program Framework 41

safe playgrounds.
o Education: teaching and training of caregivers, make the environment
child protective. Educate the family, teachers and guardians on
avoiding falls at home or in school.
o Legislation: enforce building codes and standards. All schools shall
have a health center to care for injury
o First aid training
o Establish and strengthen referral to trauma centers including
psychological treatment and rehabilitation.

Package 10: School health preparedness, response & recovery during

education in emergency
Emergency situations are becoming a recurrent phenomenon in Ethiopia. School age children are one of
the affected groups during natural and human made emergencies such as drought, conflict, disease
outbreaks, flood, earth quake, heavy winds and storms. There is a need for and quick and seasonal
assessment of emergency risks, identification of needs in case of emergency and provision of responses in
case of emergency.

Education in Emergency (EiE) has not been given adequate attention in Ethiopia. It is a legal and a moral
imperative to ensure that children continue their education without interruptions. Practices indicate that
emergency affected school age children require service provision during emergencies such as the
provision of school feeding, WASH and psycho-social support and these need to be regularly assessed
depending upon the emergency. EiE responses shall be provided with the engagement of community
members, MoE, MoH and other partners as part of the school health package.

8. Implementation modality
The implementation of the SHP requires the availability of appropriately skilled professionals, adequate
supplies, commodities, and equipment, proper information management systems, sound governance and
management, a sustainable financing mechanism and appropriate quality improvement and service
delivery outlets. Moreover, the availability of adequate space and infrastructure for proper delivery of the
service is critical. The SHP and its service provision indicators need to be integrated into the planning and
reporting system (HMIS or equivalent) for routine evaluation and monitoring. The sustainability of such
initiatives requires direct participation of school communities, students and parents in the management
and accountability of the service. Therefore, the following specifications for implementation are
proposed.

8.1. Human resources and infrastructure

To provide the quality school health package in all schools across the country, Table 3 outlines the
required human resources and infrastructure for adequate service delivery of the SHP by level of school.
The tasks of school health centers include planning of school health activities, provision of school health
Ethiopia School Health Program Framework 42

packages and reporting of school health activities. The human resource and infrastructure needs will be
revised as required based on regular assessments of workload and infrastructure.

TABLE 3 HUMAN RESOURCE AND INFRASTRUCTURE REQUIREMENTS

School level Human resource needed Infrastructure Remark
Pre- school A diploma nurse for urban KGs Three rooms with the The rural pre-school (O-class)
necessary inputs addressed through primary
education clinics.
Primary A diploma nurse OR Three rooms with the MoE will avail rooms for
Health extension worker (from necessary inputs school feeding
local health post)
Secondary A Health Officer/ BSC nurse Three rooms with the An existing psychologist will
A psychologist necessary inputs be part of the team
Tertiary A physician/health officer Four rooms with the An existing psychologist will
A nurse necessary inputs be part of the team
A psychologist
A laboratory technician
Woreda/Zone SHP – Coordinator N/A
Nutritionist

To fulfill the human resource requirement additional health workers will be deployed and they will
receive pre-deployment training on the SHP framework and implementation strategies. In addition in-
service trainings will be given regularly. Similarly, existing rooms in schools will be designated and
refurnished or new student health care centers will be built.

8.2 Supplies, equipment and drugs

An initial list of essential drugs, medical supplies and equipment required for implementation for the SHP
will be prepared. During the initial phase of the program all essential drugs, supplies and equipment will
be organized as a school health kit and will be delivered by MoH and partners to all schools. As the
program develops, school clinics will be linked to the nearby health center and they will be managed in
the same manner as health posts, whereby the health center will incorporate the drugs, supplies and
equipment needs of school clinics in their forecasting plans and fulfill distribution accordingly.

8.3 Program financing

Due to the public health importance of the SHP, the services will be provided to students free of charge.
Development partners will have a significant role in establishing the SHP. In order to create a sustainable
SHP, the Woreda administration through revenue collection and support from MoH and MoE will take
responsibility of the local SHP budget. All implementing ministries will include a list of activities and
materials pertaining to the implementation of the SHP packages in their sectoral strategy and plan. The
required finances will be budgeted for by the respective sectors as per their annual and strategic plan. In
addition, Woreda administrations should mobilize resources from the community, private sector and
NGOs which may strengthen the implementation of the program. Many aspects of the SHP packages are
already being implemented through MoH or MoE and are budgeted for in existing federal MoH or federal
MoE budgets. Therefore, the costing only includes new cost categories to the government, such as new
Ethiopia School Health Program Framework 43

hires or new capital expenditure, and does not capture costs related to increased demand of services that
are already budgeted for through the MoH or MoE, such as vaccines and deworming.

The total cost of the SHP for the first four years is ETB 11.7 billion. Overall, 44% (ETB 5.1 billion) of
the overall costs are capital costs and the rest (ETB 6.6 billion) are recurrent costs, including salaries and
medical equipment. This total cost reflects an overall financial requirement of ETB 9.3 billion in the first
3 years for both service delivery and the initial capital cost required for the SHP roll out. Starting with
Year 4 of the program, and following full roll out, the yearly recurrent cost is estimated to be ETB 2.4
billion. Detailed cost breakdowns are provided in Annex VII.

8.4 Monitoring, evaluation and research

A monitoring and evaluation plan will be in place to assess the implementation of the SHP and each
individual package. A monitoring and evaluation framework is outlined below in
Table 4, and a more detailed list of specific indicators is designated in Annex VI. The indicators are
designed to assess and measure the accessibility of the overall SHP and the individual service packages as
well as the program’s outputs, outcomes and overall impact. As needed, service delivery registers, tally
sheets and reporting formats will be provided to track data at the student’ health centers and the reports
will be integrated with the Health Management Information System (HMIS) and Education Management
Information System (EMIS). In addition, regular and integrated supportive supervisions will be conducted
by sector ministries and partners to identify the gaps in implementation and provide support accordingly.
Regular review meetings involving all concerned stakeholders will be held to evaluate the implementation
of program as well as to share best practices. In line with this, high performing (model) schools and
Woredas will be evaluated, graded and awarded based on a set of defined metrics. Moreover, for evidence
based program implementation, research will be completed to identify the implementation status,
challenges, outcomes and impact of the program and the findings will be used to improve program
implementation.

TABLE 4 M ONITORING AND EVALUATION FRAMEWORK

Input Process Output Outcome Impact
National Recruitment and Schools with the Reduced Age specific
policies and deployment of minimum package of NCDs risk morbidity and
strategies health work school-based health factors (use of mortality
Health work force services alcohol,
force Training of Health education sessions tobacco,
School health health work conducted per package physical
Improved
package, force Health services provided inactivity,
student
guidelines, job Conducting Students screened for unhealthy
performance
aids advocacy nutritional/psychosocial diet)
Register, meetings and or mental/common Reduced
reporting and sensitization childhood disease educational
referral formats workshops /congenital problems wastage Improved
Construct/assign Reduced nutritional
Code of Schools with complete
school health adolescent status of
conducts WASH facility
Medical centers Common childhood pregnancy
Ethiopia School Health Program Framework 44

supplies and Supportive illnesses managed in rate student

equipment supervisions & schools Reduced
Financing/budge review meetings Students referred to violence in
ting Supply chain health facilities schools
Infrastructure management Students dewormed
School facilities Improved student
Health facilities knowledge on healthy
behaviors
Schools with physical
activity facility
(Playground, separate
room for girls)

8.5 SHP service linkage

The school health center will be mandated to provide health promotion, disease prevention, screening and
very basic curative services. To support this mandate, strong linkage with the existing health system for
additional services is required. The linkage will be as follows: primary school to health center; secondary
school to health center or district hospital; tertiary school to general hospital or teaching hospital and it
will follow the conventional referral system for serious health problems. The school health centers will
also be linked with feeding centers in the catchment area and to the community for psychosocial support.
The service linkage is summarized in Figure 5 below.
Ethiopia School Health Program Framework 45

F IGURE 5 LINKAGE AND REFERRAL CHART FOR SHP

REFERRAL Linkage FLOW CHART

Student health problems (nutrition, WASH, Communicable and non-communicable diseases)

Concern for student Referral

network and linkage

Referral made to School Health Center:

Self (Student)
Parent/Guardian
Teacher
Administrator
Peer
Other

1. Health Worker at school assess concern by

collecting/reviewing data
2. Level and type of intervention are determined

Health Worker In-School Interventions: Health Worker Referral to

Emergency Intervention Health Center

Counseling Hospital
Consultation School Feeding Center
Diagnosis and treatment Legal Institution
Youth Friendly Centers/Clinics
Family/ Community
Ethiopia School Health Program Framework 46

9. Leadership and governance

At the national level, coordination of activities will be assured by the MoH. The MoH will collaborate
with other sectors such as the MoE, Ministry of Youth and Sport, Ministry of Water, Irrigation and
Electricity and Ministry of Agriculture in order to support the school health center based on the gap
assessment.

Both the MoH and MoE will be fully responsible for the proper implementation of the SHP. However, the
MoH will take the lead role with the MoE as co-leader of the program. The MoH will produce the needed
guiding documents, SOPs and job aids in collaboration with the MoE. In addition, the MoH will
coordinate the necessary human resource and medical logistics and oversees the implementation and
monitoring of planned activities. The MoE will show commitment by creating favorable environments
and spaces for school health centers. Partners supporting the school health centers will take part in the
whole process of intervention from the planning stage, resource mobilization and allocation to the
monitoring and evaluation of program implementation.

Since the SHP is the extension of health services to the school, the leadership and governance will follow
the existing system at Regional, Zonal and Woreda levels and be composed of representatives from
RHBs, REBs, RWIEBs, RYSBs and other stakeholders. The Woreda Health Office will be responsible
for the overall management of the school health centers. This structure is outlined in Figure 6 below and
the roles and responsibilities of each party are outlined in Table 5.
Ethiopia School Health Program Framework 47

F IGURE 6 ORGANOGRAM FOR THE SHP

FMoH & FMoE

TVET, College Health University Health Center

center
Regional Health and Education
Bureaus

Zonal Health and Education Departments Hospital

Hospital

Woreda Health and Education Offices (HR, Health center technical

Technical & Logistic support) support

School Health Center Nearest health post

(Pre-, Primary & Secondary)
Ethiopia School Health Program Framework 48

TABLE 5 ROLES AND RESPONSIBILITIES FOR THE SHP

Organizations Roles and Responsibilities
Allocation of budget and provision of logistic support to all level
Promote and advocate SHP activities, using different media outlets (both electronic and
print media)
Create an enabling environment for scale up and sustainability of SHP
Ensure quality of the SHP service provision
Ensures that package activities, strategies and results are monitored, evaluated and reported
within the HMIS and EMIS systems
Coordinate and give training (capacity development) to health workers, school community,
Joint responsibility stakeholders and other staff on SHP
of MoH and MoE Assist the Regions to identify their program gaps and management deficits and provide
them with the technical assistance or the capacity development they require
Mobilize resources for SHP implementation
Strengthening public private partnerships(PPP) to support the SHP
Joint operational and strategic planning
Joint monitoring and evaluation
Establish coordinating body
Cascade the SHP program at all levels

Leading role for the SHP

Provide for the new buildings for service provision, medical equipment, medicines,
vaccines and supplies
Prepare and disseminate SHP guideline, standards, training materials, SoP, job aids,
Ministry of Health manuals and facilitate actual implementation of guidelines including the roll out of
trainings
Design and provide in-service and other short-term training for implementation of SHP
Avail health workers and nutritionist proficiently
Coordinate all stakeholders and actors at all levels on SHP

Co-leading for the SHP

Provide for office furniture and supplies, school feeding facility, and adequate space for
nutrition sensitive agriculture practice
Facilitate implementation of guidelines
Ministry of Ensure adequate water, sanitation and menstrual hygiene facilities in schools
Education Ensure the SHP is incorporated in the curriculum
Ensure the alignment of SHP with other strategic document and manuals
Avail school psychologist at all school level
Develop SHP co-curricular materials

Consider accessibility of new water scheme to school during construction

Ministry of Water,
Consider accessibility of new Electricity line to school during construction
Irrigation and
Technical support to school as needed
Electric

Prepare different sport competitions for students and entertainment programs

Ministry of youth Strengthening and support sport training material
and Sport Give shorthand long term training to school community (different sport games and life skill)
Ethiopia School Health Program Framework 49

Create an enabling environment for scale up and sustainability of SHP

Ministry of Women Provide technical support to school as needed
and Children Affairs Give gender sensitive short-term training to school community

Promote different nutrition sensitive agriculture activities in schools

Ministry of
Provide technical support for school community
Agriculture and
Develop school gardening training materials
Natural Resource

Promote livestock and poultry initiatives in school environment and linking with school
Ministry of feeding program
Livestock and Provide technical support for school community
Fishery
Give short-term training to school community

Engage to support MoH/MoE and its structural offices at all levels to implement the SHP
to the optimal level
Adopt the package to develop promotional materials including tools, learning aids, etc.
Development Provide support to MoH/MoE in familiarization, dissemination and implementation of the
partners/ Private SHP
sector/ CSOs Collaborate with MoH/MoE in evaluating the effectiveness of the SHP
Promote SHP information to community organizations.
Provide technical support and consultation for the implementers.
Play advisory role for the service providers

Budget allocation and provision of logistic support to all level

Promote and advocate SHP activities, using different media outlets (both electronic and
print media)
Create an enabling environment for scale up and sustainability of SHP
Ensure quality of the SHP service provision
Ensures that package activities, strategies and results are monitored, evaluated and reported
within the HMIS and EMIS systems
Coordinate and give training (capacity development) to health workers, school community,
Joint Responsibility stakeholders and other staff on SHP
Of BoH and BoE Assists Zones and Woredas to identify their program gaps and management deficits and
provides them with the technical assistance or the capacity development they require
Mobilize resources for SHP implementation
Strengthening the public private partnerships (PPP) to support the SHP
Joint operational and strategic planning
Joint monitoring and evaluation
Establish coordinating body
Cascade the SHP program at Zonal, Woreda and school level

Leading role in the implementation of SHP

Provide for the new building for service provision , medical equipment , medicines,
Regional Health vaccines and supplies
Bureaus Contextualize the developed guideline, including translation to local languages; and
disseminate SHP guideline, standards, training materials, SoP, job aids, manuals and
facilitate actual implementation of guidelines including the roll out of trainings
Ethiopia School Health Program Framework 50

Designing and implementing in-service and other short-term training program for
implementation of SHP
Avail necessary human resource
Coordinate all stakeholders and actors at regional level
Support and distribute logistics all level

Co-leading role for implementation of the SHP

Provide office furniture and supplies, school feeding facility, and adequate space for
nutrition sensitive agriculture
Regional Education
Facilitate actual implementation of guidelines
Bureaus
Ensure adequate water, sanitation and menstrual hygiene facilities in schools.
Cascade and contextualized co-curricular materials

Consider accessibility of new water scheme to school during construction

Regional Water,
Consider accessibility of new electricity line to school during construction
Irrigation and
Technical support to school as needed
Electric Bureaus

Promote and conduct periodic sport competitions for students

Prepare different entertainment programs
Regional Youth and Strengthening and support sport training material
Sport Bureaus Give short and long term sport activity trainings to School community (different sport
games and life skill)

Create an enabling environment for scale up and sustainability of SHP

Regional Women
Provide technical support to school as needed
and Children Affairs
Give gender sensitive short term training to school community
Bureaus

Supply modeling of school for different nutrition sensitive agriculture activities

Regional Agriculture Provide technical support for agriculture activities
Bureaus Provide and cascade school gardening training to Zones and Woredas

Transfer the budget allocated and provision of logistic support to all levels
Promote and advocate SHP activities, using different media outlets (both electronic and
print media)
Create an enabling environment for scale up and sustainability of SHP
Ensure quality of the SHP service provision
Ensures that package activities, strategies and results are monitored, evaluated and reported
within the HMIS and EMIS systems
Coordinate and give training (capacity development) to health workers, school community,
Joint Responsibility stakeholders and other staff on SHP
Of ZoH and ZoE Assist Woredas to identify their program gaps and management deficits and provides them
with the technical assistance or the capacity development they require
Mobilize resources for SHP implementation
Strengthening public private partnership (PPP) to support the SHP
Joint operational and strategic planning
Joint monitoring and evaluation
Establish coordinating body
Cascade the SHP program at Woreda and school level
Ethiopia School Health Program Framework 51

Leading role in the implementation of the SHP

Shall provide the new building for service provision, medical equipment ,medicines,
vaccines and supplies
Contextualize the developed guideline, including translation to local languages; and
disseminate SHP guideline, standards, training materials, SoP, job aids, manuals and
Zonal Health facilitate actual implementation of guidelines including the roll out of trainings
Department Facilitating and implementing in-service and other short-term training program for
implementation of SHP
Avail necessary human resource
Coordinate all stakeholders and actors at regional level
Support and distribute logistics at all level

Co-leading role for the SHP

Provide office furniture and supplies, school feeding facility, and adequate space for
Zonal /Education nutrition sensitive agriculture
Department Facilitate actual implementation of guidelines
Ensure adequate water, sanitation and menstrual hygiene facilities in schools.
Cascade and contextualized co-curricular materials

Zonal Water, and Consider accessibility of new water scheme to school during construction
Energy Development Consider accessibility of new electricity line to school during construction
Department Technical support to school as needed

Promote and conduct periodic sport competitions for students

Prepare different entertainment programs
Zonal Youth and
Strengthening and support sport training material
Sport Department
Give short and long term sport activity trainings to School community (different sport
games and life skill)

Zonal Women and Create an enabling environment for scale up and sustainability of SHP
Children Affairs Provide technical support to school as needed
Department Give gender sensitive short term training to school community
Zonal Agriculture Supply modeling of school for different nutrition sensitive agriculture activities
and Natural Provide technical support for agriculture activities
Resource Provide and cascade school gardening training to Zones and Woredas
Department

Woreda Agriculture Supply modeling of school for different nutrition sensitive agricultural activities
and Natural Provide technical support for agriculture activities
Resource office Give short term school gardening training to school community as needed

Lead all technical part of SHP in the health center catchment

Provide logistical support (Medical equipment, medicines, vaccines and supplies)
Health center / Create an enabling environment for scale up and sustainability of SHP
Hospital
Incorporate statistics on SHP into the facility statistics (facility HMIS report)
Establish referral linkage mechanisms.
Monitor and evaluate the SHP activities
Ethiopia School Health Program Framework 52

Create sense of shared responsibility about the intervention package for the whole school
community
Establish linkage with different stakeholders facilitate on- job and other short-term training
program for implementation of SHP
Facilitate advocacy and promotion activities at school and community levels; and include
SHP as a priority agenda for the school community
Assist the school to identify their program gaps and management deficits and provides
them with the technical assistance or the capacity development they require

Own Keble education and Training board for effective implementation

Play administrative role
Administrative control of SHP staff
Jointly monitor and evaluate the SHP activities with collaboration of nearest health facility
Record and report to the respective office
Create sense of shared responsibility about the intervention package for the whole school
and surrounding community
Mobilizing and liaising with the school community including educators, the school
School (from nursery governing body and other role-players.
to university level) Ensuring that all components of the SHP packages are provided to all students
Managing newly constructed center and equipment
Build partnerships with external providers including NGOs and other community
organizations.
Implementing SHP co-curricular activities at the school level

Work with SHP staff and school community

Create an enabling environment for scale up and sustainability of SHP
Monitor and evaluate the SHP activities
Health Post
Plan the activities with collaboration of SHP
Advocate for and promote activities at school and community levels; and include SHP as a
priority agenda for their own Kebele

Monitor and evaluate the SHP activities

Advocate for and promote SHP activities
Community Support implementation process of the package at all levels
Resource mobilization and contribution.
Ensure safe and healthy learning environment

Monitor and evaluate the SHP activities

Kebele Admin Advocate for and promote SHP activities
Providing support for the successful implementation of the package

Advocate for and promote SHP activities

Students Create an enabling environment for scale up and sustainability of SHP
Engage with all activates of SHP

Advocate for and promote SHP activities

Students
Create an enabling environment for scale up and sustainability of SHP
Ethiopia School Health Program Framework 53

Associations Become involved in the implementation, monitoring and evaluation of SHP activities
Support the implementation process of the package at all levels
Establish linkage with students to SHP
Ethiopia School Health Program Framework 54

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 56

Annex 1: Pre-primary gross enrollment, by region and gender (age 4 – 6 years)

(MoE ESAA 2008 E.C./ 2015-16 G.C.)
Gross enrollment Population age 4-6 years Gross Enrollment Rate (GER)%
Region
Male Female Total Male Female Total Male Female Total
Tigray 201,078 192,581 393,659 196,209 190,685 386,894 102.5 101.0 101.7
Afar 5,314 5,363 10,677 68,257 64,617 132,875 7.8 8.3 8.0
Amhara 457,661 429,079 886,740 862,085 833,498 1,695,584 53.1 51.5 52.3
Oromia 609,605 548,421 1,158,026 1,521,774 1,492,666 3,014,441 40.1 36.7 38.4
Somali 14,738 12,199 26,937 253,497 247,933 501,430 5.8 4.9 5.4
SNNPR 16,631 14,431 31,062 43,164 41,694 84,858 38.5 34.6 36.6
Ben-Gumuz 560,170 528,396 1,088,566 785,475 770,274 1,555,749 71.3 68.6 70.0
Gambella 8,831 7,660 16,491 15,327 14,904 30,231 57.6 51.4 54.6
Harari 6,904 6,195 13,099 8,142 7,777 15,919 84.8 79.7 82.3
Addis Ababa 86,272 82,076 168,348 89,634 89,370 179,004 96.2 91.8 94.0
Dire Dawa 8,177 7,516 15,693 19,906 18,533 38,440 41.1 40.6 40.8
National 1,975,381 1,833,917 3,809,298 3,863,471 3,771,952 7,635,423 51.1 48.6 49.9
 57

Annex II: Primary gross enrollment by region and gender (Grades 1-8)
(MoE ESAA 2008 E.C. / 2015-16 G.C)
Region Gross Enrollment Population Age 7-14 GER %
Male Female Total Male Female Total Male Female Total
Tigray 590,368 548,530 1,138,898 505,704 492,790 998,494 116.74 111.31 114.06
Afar 109,274 86,130 195,404 157,522 137,492 295,014 69.37 62.64 66.24
Amhara 2,230,637 2,115,832 4,346,469 1,964,019 1,931,757 3,895,776 113.58 109.53 111.57
Oromiya 4,183,219 3,609,667 7,792,886 3,765,079 3,709,130 7,474,208 111.11 97.32 104.26
Somali 512,650 376,793 889,443 492,482 434,785 927,267 104.10 86.66 95.92
Benishangul
126,454 102,693 229,147 106,548 102,576 209,124 118.68 100.11 109.57
Gumuz
SNNP 2,458,662 2,173,362 4,632,024 2,014,753 1,994,844 4,009,597 122.03 108.95 115.52
Gambella 63,798 53,601 117,399 39,718 36,338 76,056 160.63 147.51 154.36
Harari 24,290 20,027 44,317 20,952 20,131 41,083 115.93 99.48 107.87

Addis Ababa 232,626 287,244 519,870 175,365 179,977 355,342 132.65 159.60 146.30

Dire Dawa 37,973 33,611 71,584 53,043 48,940 101,982 71.59 68.68 70.19

Total 10,569,951 9,407,490 9,977,441 9,295,184 9,088,760 18,383,944 113.71 103.51 108.67
 58

Annex III: Secondary Gross Enrollment by region and gender (Grades 9-12)
(MoE ESAA 2008 E.C / 2015-16 G.C.)
Gross Enrolment Population Age 16-19 GER %
Region
Male Female Total Male Female Total Male Female Total
Tigray 106,227 106,794 213,021 236,630 232,060 468,690 44.89 46.02 45.45
Afar 8,587 4,628 13,215 86,495 66,797 153,293 9.93 6.93 8.62
Amhara 289,198 307,402 596,600 911,356 889,615 1,800,970 31.73 34.55 33.13
Oromiya 421,232 342,410 763,642 1,650,451 1,624,492 3,274,943 25.52 21.08 23.32
Somali 33,737 17,531 51,268 259,356 198,815 458,171 13.01 8.82 11.19
Benishangul
16,631 13,024 29,655 47,880 46,897 94,777 34.73 27.77 31.29
Gumuz
SNNP 302,730 247,541 550,271 897,146 889,718 1,786,864 33.74 27.82 30.80
Gambella 16,755 10,021 26,776 19,401 17,568 36,969 86.36 57.04 72.43
Harari 3,784 3,448 7,232 9,924 9,999 19,923 38.13 34.48 36.30
Addis Ababa 69,572 85,888 155,460 87,153 101,805 188,958 79.83 84.36 82.27
Dire Dawa 7,593 6,430 14,023 27,322 25,496 52,818 27.79 25.22 26.55
Total 1,276,046 1,145,117 2,421,163 4,233,113 4,103,262 8,336,375 30.14 27.91 29.04
 59

Annex IV: Number of schools with and without clinics (MoE 2015/16 G.C.)
# of pre- # of primary # of primary schools with # of secondary # of secondary schools
Region
schools schools clinic infrastructure schools with clinic infrastructure
Tigray 208 2124 602 189 46
Afar 38 761 129 34 3
Amhara 405 8627 1774 433 119
Oromia 1631 13853 2357 1297 220
Somali 33 1188 282 124 35
B/Gumuz 32 571 118 68 11
SNNPR 761 6452 1447 705 197
Gambella 21 287 43 53 12
Harari 52 87 60 15 8
Addis 1106 804 731 217 186
Ababa
Dire Dawa 104 113 94 21 14
National 4,391 34,867 7,637 3,156 851
 60

Annex V: Detailed School Health Program Packages

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
1 SBCC and life Build positive Self-awareness, Age appropriate Teachers Develop interactive and attractive
skills healthy behavior assertiveness, coping health message audio Health visual learning through posters,
Skills of with emotions visual and printed workers pictorials, cartoon films, best
Knowing and Empathy, effective (drama, songs, Parent storytelling, role plays, application
living with communication Mezmur, poems, engagement and card games, computer
oneself nonviolent conflict teaching games, role Teachers applications set according to their
Skill of knowing resolution plays storytelling, Health age etc.
and living with Creative thinking, pictorials, carton workers Identifying /observing preschoolers
others critical thinking, films) Parent characteristic’s that deviate from the
Skills for problem solving Speaking books engagement normal behavior and give special
making effective (puzzle) Puzzles support and create linkage to PHCU
decision Teaching games Prepare interactive tools/guides to
Audio visual assess the different child cognitive,
Role plays social, psychological, developmental
Interactive dramas issues
Skill building activities for
parents/parenting,
Skills building for parents with
special need children.
Develop / adapt life skill training
manual for teacher, facilitators and
club members to implement
Prepare age appropriate and engaging
life skill activity guide for teacher,
facilitators and club members to
implement
Conduct TOT for KG teachers,
facilitators and Student leaders
(Grade 5- 8 could practice leading
with the support of KG teachers)
 61

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Prepare age appropriate teaching aids

2 Nutritional Nutrition Awareness creation Weight scale Nutritional screening and follow up
services assessment and on nutrition Height scale Growth monitoring and promotion
monitoring assessment and MUAC tape School meal assessment (adequacy,
Food and monitoring for School meal quality and safety)
nutrition parents assessment (safety, Regular monitoring
education and Age appropriate quality, diversity and Referral linkage
counseling Education/ promotion adequacy) Education on diversity, balanced diet,
Nutritional on diversity, balanced Charts healthy dieting, food safety (food
support for diet, healthy dieting, Registration and item selection, processing, storage)
malnourished food safety referral slip Training to pre- school facilitator
children Promotion on healthy Food groups Parental counseling
School feeding diet planning Food pyramid Celebration of national nutrition day
program Food substitution for Pictures showing Nutritional status assessment
Micronutrient diversification poor and good Referral linkage to higher level
Supplementation Home based diet nutrition Case management
(Vit A, Zinc, diversification Supplementary foods, Supply management
Iron folate, Fortification of therapeutic foods Parental education and counseling
calcium) products with (RUTF), and Recording and reporting
micronutrient multivitamins Assessment of eligibility of school
Antibiotic /students for school feeding program
Case management Supply of food items
guide line Cleaning
School feeding guide Food serving
lines
Link small holder farming
Food items
WASH linkage
Kitchen and utensils
Age and case identification
(room for store,
Supply management
plates, cups)
Improved stoves
Water, electricity/
Buta gas), serving
 62

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
place
National
micronutrient guide
line
Registration
Nutrition supply
(Vit A, zinc, iron,
folic acid, calcium)
3 Water Personal hygiene IEC/BCC materials Infrastructures of Promotion hands washing with soap
sanitation and promotion Mini media toilets and Urinals or substitute. (Every critical time)
hygiene Promotion of Role playing (isolated for male and Personal hygiene monitoring
(WASH) appropriate Puppet show female) program (Washing of body and hair,
utilization and History telling Clean and adequate Combing hair, cutting nails, brushing
management of supply of water teeth, face washing, neatness of dress
latrine Water treatment and wearing shoes or slippers)
Water supply chemical Hand washing day celebration
Food hygiene Manuals of waste Provision of Improved latrine
Solid and Liquid management Awareness creation of the safe use of
waste Infrastructures of toilets and urinals
management Waste disposal Awareness creation and promotion of
Greenery of the depend on the area appropriate Anal cleansing material
school (sewerages lines, Toilet day celebration
environment composting areas, Provision of safe drinking water
Compound pits) Awareness creation drinking water,
sanitation Standard design of handling, storage and utilization
Ventilation of class room Children know how to store food
class rooms/ safe Plants to be planted appropriately and recognize common
class rooms signs of spoiled food
Meal box checking regularly
Medical checkup of food handlers
(depend on type of School)
Waste disposal site preparation
Facilitate collection and disposal of
 63

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
solid and liquid waste management
(putting dust pin in front of classes)
Sanitation campaign
Construction and ready waste
management sewerage lines,
composting areas and pits
Inspection of each classroom
cleanliness every day
Avail plants for school area greenery
Routine follow up of class rooms
Awareness creation of communicable
disease (influenza, TB)
4 Management Diagnosis and Age appropriate First aid kit (Plaster, Health Focused training of health workers,
of common management of SBCC on common gauze, cotton, iodine, workers, HEWs and teachers on the common
infections, common diseases alcohol, scissor, HEWs and diseases and care
infestations childhood Educate teachers on sutures) teachers Avail appropriate job aids
and disorders illnesses prevention of the Snellen’s chart Supportive supervision from health
(diarrhea, common diseases and Oral and teeth model offices
pneumonia and early detection of for demonstration of Recording and reporting of routine
malaria, etc. signs and symptoms teeth brushing vaccination services
ICCM/ IMNCI Utilize appropriate Otoscope Avail disease distribution dossier
Treatment of models to Job aids Avail anti-helminthic drugs
scabies/ skin demonstrate care ITN Train and educate health workers
diseases and Strengthen ICCM/IMNCI Monitor and evaluate implementation
intestinal interpersonal algorithm
parasitosis communication Essential equipment
Management of during student and drug list
minor wounds encounters Broad spectrum anti-
and splint Education on WHO 5 helminths
Provide care on key rules of food (mebendazole,
eye, ear and safety albendazole and
upper respiratory Linkage with WASH prazequantel)
tract infections
 64

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Provide dental
care
Referral services
School based
mass deworming

5 Routine catch Using Educate teachers on Cold chain boxes HEWs, Train health workers on
up vaccination immunization target diseases for Safety boxes Teachers and immunization in practice
and card, routine vaccination and EPI monitoring chart other HWs Avail job aids
immunization screening for available vaccines in Tally sheets, Appropriate venues for vaccination
vaccination Ethiopia registration books sessions in schools; Session plan for
status, especially Strengthen and reporting formats vaccination;
during interpersonal Student health profile Supportive supervision from health
enrollment communication on folder offices
Vaccinate based vaccine schedule, Recording and reporting of routine
on the child’s appointment and and supplemental vaccination
vaccination adverse events services
status for routine following
immunization immunization
Measles Rubella Age appropriate
 65

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Other SBCC on targeted
supplemental diseases and vaccines
Immunizations
as recommended
by MoH
6 Sexual and NA NA NA NA NA
reproductive
health (SRH)
7 HIV/STI NA NA NA NA NA
8 Mental, Screening of Promote warm, Data collection tools, Trained Develop policy/rules/code of conduct
neurological mental illness, friendly and reporting formats and Nurse on substance use, violence, bullying
and substance disorders and rewarding learning referral forms Psychologist in school
use disorders risk factors school environment. Job aids Prepare training materials/job
Screen children Cooperation rather aids/guideline
for mental than competition Providers training for Health care
illness and Supportive and open providers and mangers , teachers
disorders of at communications. community and religious leaders ,
school entry Inform children of families , and other relevant bodies
annually what they can do if Orientation for students/family/care
Identifying they are being givers
children with abused, or even Conduct advocacy activities to
risk factors suspect that a friend enforce the education polices and
(social, or relative is being school standards on substance use
economic, abused in the school related issues.
behavioral or their home
problems) in the Promotes the right of
class by teachers boys and girls
Linking with the through equal
school health opportunities and
centers for democratic
further procedures
assessment and
actions
 66

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Periodic
screening
integrated with
other health
screening
program.
Referral for
further
psychiatric
treatment and/or
social supports
Prevention of
physical
punishment,
bullying,
harassment and
violence
9 Prevention of Develop Support schools to Safe field for playing Home room Encourage children to have at least
NCDs and physical activity provide students with Locally available teacher 10 minutes of playing physical
injuries and fitness daily physical recreational Sport teacher activity daily at flag ceremony
education and should facilities& tools Supportive Physical activity should consider
be equipped with First aid kid nurse growth and developmental status of
appropriate facilities Training manuals children
and equipment. Lesson plans Playing games, sports, walk as means
of transportation, recreation, physical
education, or planned exercise, in the
context of family, school, and
community activities can be held
Injury Health education on Appropriate SBCC Teachers, Awareness raising of school
prevention and Injury prevention and materials guards, health community and parents on injury
care control Training manuals workers, prevention
Awareness raising psychologist , Advocacy for legislation and
activities to school regulation and enforcement---seat
 67

PRE-SCHOOL (AGES 4 -6)

. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
community , students community belt, helmet, zebra crossings
and parents on injury Conduct health education sessions
prevention strategies Capacity building for school
Advocacy to ensure community on injury prevention and
policies and control
legislations are in Ensure safe school environment, play
place on injury grounds etc.
prevention and Safe school buses, taxis, and
control disciplined drivers
Treating minor First aid kit Nurse Treating Minor injuries
Injuries Minor injury Teachers Referral
Referral linkage , and treatment tools Assistants Follow up/rehabilitation
rehabilitation/follow Psychosocial support
up providing training
for health workers
10 School health Provide micro Create awareness Micronutrients Nurse, HEWs Awareness raising of school
preparedness nutrient using pictures, songs Foods or teacher community and parents on
and readiness supplement and drama Drugs emergency preparedness and
in education Provide Anti-pains readiness
during emergency food Establish emergency team with the
emergency supplies school community
Provision of Screen for malnutrition and
ORS and dehydration link with nearby health
medical supplies facility
Sensitize Provision of micronutrient
children on supplements (such as vitamin A, iron
emergency and iodine)
situations Provide psychosocial support
 68

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
1 SBCC and life Build positive Age appropriate Teachers School health action committee
skills healthy behavior health message audio Health (school administration , PTAs,
Inter personal visual and printed workers PHCU, Parents, students, teachers)
communication (drama, role play, Parent Strengthen mini-media, edutainment
(child to child music, poems, engagement programs
approach 1 to 5) teaching games, Integrate school health clubs
Mass pictorials, Capacity building on effective
communication demonstrations) communication skill for all
Models / implementers (teachers, facilitators,
demonstration on health workers).
health packages Capacitate on the development of
Mini medias Edutainment activities (drama, role
Smart projector play (participatory theatre), sing,
Speaking book poems, videos, teaching games (card
Comic books and application), pictorials etc.…)
Standardize age appropriate health
messaging
Produce and disseminate age
appropriate child appealing health
education and promotion messages
and different SBCC materials
(posters, leaflets, banners, billboards
etc.)(centrally)
Conduct different festivals like
parents day ,annual school health day
events
Organize different health-related
question and answer events
Participative musical sport games
tide to key health messages
Strengthen 1to5 student linkage
Facilitate health education session
(period)
 69

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Facilitate health education to be
given by health workers
Pre service training for teachers at
each level
SBCC and life Inter personal Guiding manuals Teachers and Adapt training curricula to train
skills in communication SBCC materials, health TOTs, Pts.)
primary 2nd (Child to child audio, audio visual workers Recruit Peer health Educators (PE)
cycle approach 1 to 5) (TV, DVD) and Psychologists based on the selection criteria
(5-8) Peer health printed, fact sheets, TOT for peer health educators
education role play/drama Conduct, monitor and support the
School scripts peer education and life skill session
community School gardening by trained peer health education
conversation, Smart projector Manual and activity book for club
Guidance and Speaking book management
counseling Comic books Establish and strengthen School
Awareness health clubs
creation Strengthen mini-media, parents day
Strength and edutainment committee, health
adolescent spot
friendly service Conducting an effective dialogue
School health with students on health risks at this
days age, means of prevention,
Mass transmission
communication Debating
(school mini Participative musical sport games
media, tide to key health messages(e.g.
educational mass modified abebayehosh, etemeyite,
media, meharebenyayachihu)
community radio) Education on Adolescence,
Community Biological, physical and Behavioral
outreach/commun changes related with age
ity, health days, Age appropriate content based and
campaign etc. time allocation for health education
 70

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
School health in regular bases
exhibition. Edutainment/ folk media/hidden
drama/street show
Integration with all current
government educational curriculum
and trainings
Bring health services to school
environment and invite parents as a
symposium
Skills of Knowing Self-awareness Facilitation manuals, Teachers Develop / adapt life skill training
and living with Assertiveness, teaching aids Health manual for teacher, facilitators and
one self Coping with Puzzles worker club members to implement
Skill of knowing emotions, self- Teaching games Prepare age appropriate and engaging
and living with esteem, coping with Audio visual life skill activity guide for teacher,
others stress Role plays facilitators and club members to
Skills for making Empathy, effective Interactive dramas implement
effective decision communication Training of Trainers (TOT) on life
Skills as a tool for nonviolent conflict skill facilitation
making good resolution, Train and supervise the facilitators
leaders negotiation relating Conduct life skill sessions
with others, Follow-up and monitor sessions
managing peer Build skills on Skills of Knowing and
relation ship living with one self, Skill of knowing
Creative thinking, and living with others ,Skills for
critical thinking, making effective decision
problem solving, Strengthen school health cubs by
decision making using student leaders from LS
sessions
 71

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
2 Nutritional Cooking Awareness creation Weight scale Nutritional screening
services Demonstration about nutritional Height scale Micronutrient assessment
(for primary and assessment MUAC tape School meal assessment (adequacy,
2nd cycle ) School meal quality and safety)
assessment (safety, Regular monitoring
quality, diversity and Referral linkage
adequacy)
Charts
Registration and
referral slip
Food and Education/ Food groups, Education and counseling on
Nutrition promotion on Food pyramid, diversity, balanced diet, healthy
Education and diversity, balanced Pictures showing dieting, food safety (food item
counseling diet, healthy dieting, poor and good selection, processing, cooking and
food safety (best nutrition preservation/ storage
before, optimum Establish and strengthening nutrition
heat, storage/ club
preservation) Parental counseling
Celebration of national nutrition day
Nutritional Awareness creation Supplementary Nutritionist Nutritional stats assessment
support for Acute on prevention of foods, therapeutic Referral linkage to higher level
malnourished malnutrition foods (RUTF), and Case management
(supplements, Benefits of balanced multivitamins Supply management Parental
prescription and diet Antibiotic education and counseling
counseling) Case management Recording and reporting
guide line
School feeding Promotion on School feeding guide Food Assessment of eligibility of school /
program (To be healthy diet lines technologist students for school feeding program
implemented by planning Food items Supply of food items
MoE scale up Food substitution Kitchen and utensils Food preparation and cooking
plan and is not for diversification (room for store, Cleaning
costed in this Promotion on Home plates, cups) Food serving
framework) Grown School Improved stoves
 72

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Feeding (HGSF) Water, electricity/ Link small holder farming
(for primary 2nd Buta gas), serving WASH linkage
cycle ) place

School gardening Promotion on Vegetable seed Agriculturalis Supply of seeds and seedlings
for teaching easy homestead Fruit seedlings t Avail and prepare plots
method of food gardening (take Plot for fruits and Trained Education on plot preparation, crop
diversification home skill) vegetables teacher diversification, cropping/planting,
Water facility for seed selection/nutrition sensitive
irrigation agroecology factors, irrigation,
Take home /Homestead gardening
Cooking Diet planning Recipe book Preparation or availing of cooking
demonstration Healthy cooking Cooking utensils demonstration material
(for primary 2nd demonstration Charts and tables for Link with WASH activates
cycle) Food safety RDA demonstration
Biogas
Solar energy
Food items
Iodized salt taste kit
Micronutrient Home based diet National Age and case identification
Supplementation diversification micronutrient guide Supply management
(Vit A, Zinc, Iron Fortification of line
folate, calcium) products with Registration
micronutrient Nutrition supply (Vit
Promotion of A, zinc, iron, folic
iodized salt acid, calcium)
utilization

3 Water Personal hygiene IEC/BCC materials Infrastructures of Promotion hands washing with soap
sanitation and promotion Software application toilets and Urinals or substitute. (every critical time)
hygiene Mini media (isolated for male Personal hygiene monitoring
(WASH) Quizzes and female) program
 73

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Conversations Mosquito nets for Regular washing of body and hair,
Role playing boarding schools Combing hair, cutting nails, brushing
Dancing teeth, face washing , neatness of
Drawing or painting dress and wearing shoes or slippers)
Life skill training Computer/Mobile game Application
(WASH snake and ladders board
with dice or other games)
Hand washing day celebration
Fully integrated life skill education
focusing on key hygiene behaviors
and using participatory teaching
techniques
Established different WASH clubs
from model students
Awareness creation on Mosquito nets
utilization
Promotion of IEC/BCC materials Provision of improved latrine
appropriate Role playing Awareness creation of the safe use of
utilization and SLTSH approach toilets and urinals
management of Awareness creation and promotion of
latrine appropriate Anal cleansing material
SLTSH (school lead total sanitation
and hygiene) approach
Construction of model latrine for
demonstration
Toilet day celebration
Water supply IEC/BCC materials Clean and adequate Provision of safe drinking water
Demonstration water supply of water Awareness creation drinking water,
treatment chemical Water treatment handling, storage and utilization
utilization chemical Awareness creation on water
treatment chemical utilization
Food hygiene IEC/BCC materials Children know how to store food
appropriately and recognize common
 74

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Role playing signs of spoiled food
Medical checkup of food handlers
(depend on type of School)
MHM service Role playing Fully equipped MHM Awareness creation for menstrual
Quizzes room hygiene management (MHM)
Conversations Promotion of sanitary pads
Focus group preparation using local material
dissection Fully equipped with necessary
material
Solid and liquid IEC/BCC materials Manuals of waste Waste disposal site preparation
waste management Facilitate collection and disposal of
management Infrastructures of solid and liquid waste management
Greenery of the Waste disposal (putting dust pin in front of classes,
school depend on the area library, office)
environment (sewerages lines, Sanitation campaign
Compound composting areas, Construction and ready waste
sanitation pits) management sewerage lines,
Standard design of composting areas and pits
class room Inspection of each classroom
Plants to be planted cleanliness every day
Cleaning materials Avail plants for school area greenery
including detergents, Avail PPE for the school community
disinfectants and educate about how to utilized
and importance
Elimination of breeding places of
mosquitoes
Ventilation of IEC/BCC materials Routine follow up of class rooms
class rooms/ safe Awareness creation of communicable
class rooms disease (influenza, TB)
4 Management Diagnosis of Enhance school mini First aid kit (Plaster, Teachers Focused training of health workers
of common common media for education. gauze, cotton, iodine, Health worker on the common diseases and care
infections, outpatient Provide IEC alcohol, scissor, Health Supportive supervision from health
infestations diseases materials for sutures) offices
 75

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
and disorders Treatment of common diseases Snellen’s chart extension Recording and reporting of routine
scabies/ skin and promote WASH Oral and teeth model workers and supplemental vaccination
diseases (fungal Educate teachers and for demonstration of services
and bacterial students on teeth brushing Avail disease distribution dossier
infections); and prevention of the Otoscope Avail anti-helminthic drugs
intestinal common diseases Essential equipment Train and educate health workers and
parasitosis and early detection and drug list (Annex) teachers
Prevention, of signs and Monitor and evaluate implementation
diagnosis and symptoms Broad spectrum
management of Utilize appropriate Anti-helminths
malaria models to (Mebendazole,
Management of demonstrate care Albendazole and
minor wounds ITN prazequantel)
and splint Strengthen
Provide care on interpersonal
eye, ear and communication
upper respiratory during student
tract infections encounters
Provide dental Education on Hand
care and face washing
Referral services Education on WHO
School based 5 key rules of food
mass deworming safety
Linkage with
WASH
5 Routine and Routine screening Enhance school mini Cold chain boxes Teachers Train health workers on
catch up for vaccination media for education. Safety boxes Health worker immunization in practice
vaccination status, especially Educate on target EPI monitoring chart Additional Appropriate venues for vaccination
and during enrollment diseases for Tally sheets, health worker, sessions in schools; Session plan for
immunization Provision of vaccination in registration books HEWs and vaccination;
vaccination Ethiopia and reporting teachers for Supportive supervision from health
services: HPV Debating on formats supplemental offices
vaccination for vaccines and target Student health immunization Recording and reporting of routine
 76

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
adolescent girls, diseases among profile sheets activities and supplemental vaccination
school Tetanus students services
and diphtheria Educate on vaccines
(Td) available for routine
Vaccinate based and supplemental
on the child’s immunization
vaccination status Strengthen
for routine interpersonal
immunization communication on
Hepatitis B vaccine schedule,
Vaccinations appointment and
Measles Rubella adverse events
vaccines following
Supplemental immunization
Immunizations as
recommended by
MoH
6 Sexual and Reproductive Adolescence, body Posters, booklet, Teachers, Develop tailored SBCC materials and
reproductive health counseling and emotional leaflets, sanitary peer messages
health services and education (5- changes pads, teaching aids educators Providing sanitary pads and how to
8 grade students) Menstruation, Mini media nurses use it
Age appropriate abstinence, Visual teaching aids Establishment of different clubs and
SRH information HTP (early Story telling on SRH engage them in open discussion
should be (for 1st marriage, FGM issues about sexuality,
cycle E.g. About violence, early Registries and Counseling regarding to all matters
their body parts, sexual debut) formats related to SRH including
gender related Comprehensive Thermometer developmental changes
roles, etc.) sexuality education BP apparatus Dx and Rx of menstrual disorders,
HPV vaccine Age appropriate Weight scale Technical capacity building of
Support on sexual education to Test kit service providers
educating on help them delay Drugs Referral for further consultation,
prevention of sexual activity treatment and care
HTPs like child Regular meetings with parents or
 77

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
marriage guardian on SRH issues
Developing guideline about consent
issues for provision of SRH services
for those under 18 years of age
Provide legal support to prevent child
marriage like certification
7 HIV/STI Provider initiated Awareness creation Registries and Nurse Provide clinical care activities
HIV counseling on HIV and STI for formats Create referral linkage
and tasting the target groups and Thermometer Monitor referrals
Referral for STI community at large BP apparatus, Develop tailored age appropriate
Dx and Rx by Weight scale IEC/ BCC materials (music, game
using syndromic VCT room playing materials, models, pictures,
approach Test kit etc.)
Referral to Drugs Organize awareness creation events
VMMC, if Age appropriate like WAD
desired Audio visual and Generate and transmit HIV/STI
Refer and printed BCC prevention information through mini-
facilitate timely materials medias, clubs SRH SMS message
entry to pre ART Mini media and Club Provide tailored Psychosocial
and ART service materials support activities
Mini media ICT equipment
service
Student clubs
Psychosocial
support
Provide IT
supported
information
Counseling on
delay sexual
debut , proper and
consistent use of
condoms
 78

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
 79

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
8 Mental, Screening of Advocate to Data collection tools, Trained Nurse Develop policy/rules/code of conduct
neurological mental illness, prohibiting licensing reporting formats Psychologist on substance use, violence
and substance disorders and risk business companies and referral forms Training materials/job aids/guideline
use disorders factors in regarding to Job aids Conduct training for Health care
Screen students substances near to providers/teachers
for mental illness schools compound. Orientation for students/family/care
and disorders at Prohibit tobacco and givers
school entry alcohol advertising Advocacy to enforce the
annually in all school code/religious/community
Identifying premises leaders/government officials
students with risk Prepare content of information and
factors (social, design mobile applications
economic, Design web sites for key message
behavioral dissemination
problems) in the
class by teachers
Linking students
with the school
health centers for
further
assessment and
actions
Periodic
screening for
illness and
disorders
integrated with
other health
screening
program
Referral for
further
psychiatric
 80

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
treatment and/or
social supports
Prevention of
physical
punishment,
bullying,
harassment and
violence
Follow up and
management of
substance use
(use of
psychoactive
substances, khat,
alcohol, and
tobacco) and
violence in school
premises and
during all school-
sponsored
activities
9 Prevention of Adoption of Advocate on policies Weight scale Nurse Weight, Height and BMI assessment
NCDs and healthy dietary that support healthy Height scale Home room Dietary habit assessment
injuries habits diets at school and Checklist for diet teacher and Advise and counseling on healthy
limit the availability diary assistant diet to parents
of products high in Pictures (Healthy Check lunch boxes for hygiene,
salt, sugar and fats food versus quantity, quality and variety of foods
Prohibition of unhealthy food) and drinks
promotions on soft Educating students about what is
drinks, sweets and good and bad food and drink
foods which are risk
factors for obesity
Healthy dieting
 81

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
(balanced calorie,
nutrient and fiber
consumption; water
consumption,
physical exercise,
Energy balance)
Importance of
consuming variety
of food items
Promote Physical Support Schools to Safe Field for Home room Encourage children to have at least
activity and provide students playing teacher 15-20 minutes of moderate to
recreational with daily physical Locally available Sport Teacher intensive physical exercise for 3-5
activities education and recreational facilities days per week at flag ceremony
Develop physical should be equipped Physical exercise and fitness
exercise and with appropriate according to the growth and
fitness facilities and development status of the students
equipment
Injury prevention Health education on Appropriate SBCC Teachers Awareness raising of school
and care Injury prevention materials Guards community and parents on injury
and control Training manuals Health prevention
Awareness raising workers Advocacy for Legislation and
activities to school Psychologist regulation and enforcement---seat
community , Community belt, helmet, zebra crossings
students and parents Conduct health education sessions
on injury prevention Capacity building for school
strategies community on injury prevention and
Advocacy for control
policies and Ensure safe school environment, play
legislations on injury grounds etc.
prevention and Safe school buses, taxis, and
control disciplined drivers
 82

PRIMARY EDUCATION [1st CYCLE (GRADE 1-4) & 2nd CYCLE (GRADE 5-8)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Treating minor First aid kit, minor Nurse Treating minor Injuries
Injuries injury treatment tools Teachers Referral linkage , and
Referral linkage, Assistants Rehabilitation/follow up
Rehabilitation/ Providing training for health workers
follow up
Providing training
for health
workers
Care of Children Diabetes education,
and adolescents counseling and care
with major NCDs Asthma education,
(with DM, Heart counseling and care
disease, Epilepsy, Epilepsy education,
Cancer, Asthma) counseling and care
Cancer education,
counseling and care
Heart disease
education,
counseling and care
10 School health Provide micro Create awareness Micronutrients Nurse, HEWs Awareness raising of school
preparedness nutrient about possible Foods or teacher community and parents on
and readiness supplement emergencies Drugs emergency preparedness and
in education Provide Anti-pains readiness
during emergency food Establish emergency team with the
emergency supplies school community
Sensitize children Screen for malnutrition and
on emergency dehydration link with nearby HC
situations Provision of micronutrient
supplements (such as vitamin A, iron
and iodine)
Provide psychosocial support
 83

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
1 SBCC and life Social Behavioral School Community Manuals, activity Teachers Develop / adapt life skill training
skills Change Conversation guides Health manual for teacher, facilitators and
Communication Peer health Teaching aids, audio Workers club members to implement
Skills of Knowing Education visual and printed Psychologist Prepare age appropriate and engaging
and living with Youth Dialogue, materials life skill activity guide for teacher,
one self Guidance and Speaker (for bigger facilitators and club members to
Skill of knowing Counseling, events) implement
and living with Mentoring Age appropriate Trainers (TOT) on life skill
others Mini media and club SBCC materials facilitation
Skills for making establishment (flyers, audio visual Train and supervise the facilitators
effective decision Voluntary services materials) that and different club leaders
Skills as a tool for Promotion of health teaches on topics of Conduct life skill sessions
making good life style practices Youth friendly Follow-up and monitor sessions
leaders Modeling/health magazines Build skills on communication,
Application of life ambassador students critical thinking, managing emotions,
skills in the world Self-awareness, negotiation, decision making, value
of work Assertiveness, clarification, peer pressure resistance,
Coping with Assist students and club leaders on
emotions, self- periodic forums (where experienced
esteem, coping with speakers & role models invited), Ted
stress like conferences, festivals on
Empathy, effective different health topics for larger
communication, community
nonviolent conflict
resolution,
negotiation, relating
with others,
managing peer
relation ship
Creative thinking,
critical thinking,
problem solving,
decision making
 84

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
2 Nutrition Food and Education/ Charts, Education and counseling on
services nutrition promotion on Food groups diversity, balanced diet, healthy
Education and diversity, balanced Food pyramid dieting, food safety (food item
counseling diet, healthy dieting, selection, processing, cooking and
food safety (best preservation/ storage)
before, optimum Supporting nutrition club
heat, storage/ Parental counseling
preservation) Calibration of national nutrition day
Nutritional Awareness creation Supplementary Nutritional status assessment and
support for Acute on prevention of foods, therapeutic linkage with health center
malnourished malnutrition foods (RUTF), and Case management
(Supplements, Benefits of balanced multivitamins Supply management
prescription and diet, diversification Nutrition supply (Vit Parental education and counseling
counseling) and fortification A, zinc, iron, folic Recording and reporting
acid, calcium)
Antibiotic
Case management
guide line
School feeding Promotion on School feeding guide Assessment of eligibility of school /
program healthy diet lines students for school feeding program
planning Food items Supply of food items (selection)
Food substitution Kitchen and utensils Food preparation and cooking
for diversification (room for store, Cleaning
Promotion on Home plates, cups), Food serving
Grown School Improved stoves Link small holder farming
Feeding (HGSF) Water, electricity/ WASH linkage
Buta gas), serving
place
School gardening Education on plot Vegetable seed Supply of seeds and seedlings
preparation, crop Fruit seedlings Avail plots
diversification, Plot for fruits and Take home /Homestead gardening
cropping/planting, vegetables
 85

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
seed Water facility for
selection/nutrition irrigation
sensitive
agroecology factors,
irrigation, use of
waste for
fertilization/soil
fertility, natural
resource
management,
economical use of
vegetable plot
(Urban agri), pest
control,
Promotion on
homestead
gardening
3 Water Personal hygiene IEC/BCC materials Infrastructures of Environmenta Promotion hands washing with soap
sanitation and Software application toilets and Urinals l Health or substitute. (every critical time)
hygiene Mini media (isolated for male Public Health Hand-washing points
(WASH) Quizzes and female) Officer Mobile game application (WASH
Conversations snake and ladders board with dice or
Role playing and other games)
Dancing Hand washing day celebration
Drawing or painting Fully integrated life skill education
Life skill training focusing on key hygiene behaviors
and using participatory teaching
techniques
Established different clubs from
model students (Eye health,
Menstrual hygiene management)
Awareness creation of Mosquito nets
utilization for boarding schools
 86

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Promotion of IEC/BCC materials Provision of Improved latrine
appropriate Role playing Awareness creation of the safe use of
utilization and SLTSH approach toilets and urinals,
management of Awareness creation and promotion of
latrine appropriate Anal cleansing material
SLTSH (School Lead Total
Sanitation and Hygiene) approach
Toilet day celebration
Water supply IEC/BCC materials Clean and adequate Provision of safe drinking water
supply of water Awareness creation Drinking Water
Water treatment Handling, Storage and
chemical Utilization
Food hygiene Students know how to store food
appropriately and recognize common
signs of spoiled food
Medical checkup of food handlers
(depend on type of School)
MHM service Role playing Fully equipped Awareness creation Menstrual
Quizzes MHM room hygiene management (MHM)
Conversations Promotion of sanitary pad
Focus group preparation using local material
dissection Fully equipped Menstrual hygiene
management room with necessary
material
Solid and Liquid IEC/BCC materials Manuals of waste Waste Disposal site preparation
waste management Facilitate collection and disposal of
management Infrastructures of solid and liquid waste management
Greenery of the waste disposal (putting dust pin in front of classes,
school depend on the area library, office …)
environment (sewerages lines, Sanitation campaign
Compound composting areas, Construction and ready waste
sanitation pits) management sewerage lines,
Standard design of
 87

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
class room composting areas and pits
Plants to be planted Inspection of each Classroom
Cleaning materials cleanliness every day
including detergents, Avail plants for school area greenery
disinfectants Avail PPE for the school community
and educate about how to utilized
and importance
Elimination of breeding places of
mosquitoes and other insects
Hazardous waste Personal protective Awareness creation about hazardous
management / equipment waste
laboratory settings Chemicals
Electronics waste
Ventilation of Routine follow up of class rooms
class rooms/ safe Awareness creation of communicable
class rooms disease (influenza, TB,)
5 Management Diagnosis of Enhance school First aid kit (Plaster, Teachers, Focused training of health workers
of common common mini media for gauze, cotton, iodine, HEWs, on the common diseases and care
infections, outpatient education. alcohol, scissor, Nurses Supportive supervision from health
infestations diseases Provide IEC sutures) School Health offices
and disorders Treatment of materials Snellen’s chart worker Recording and reporting of routine
scabies/ skin Educate on Oral and teeth model vaccination services
diseases; and prevention of the for demonstration of Avail disease distribution dossier
intestinal common diseases teeth brushing Avail anti-helminthic drugs
parasitosis and early detection Otoscope Train and educate health worker and
Management of of signs and Student health teachers
minor wounds symptoms profile sheet Monitor and evaluate implementation
and splint; Utilize appropriate Essential equipment
Provide care on models to and drug list (annex)
eye, ear and upper demonstrate care Broad spectrum
respiratory tract Strengthen Anti-helminths
infections interpersonal (Mebendazole,
 88

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Provide dental communication Albendazole and
care during student prazequantel)
Referral services encounters -
Deworming/ Education on Hand
provision of anti- and face washing
helminthic drugs Education and skill
based on on WHO 5 key rules
respective of food safety)
helminth (WASH linkage)
prevalence
5 Routine catch Routine screening Enhance school Sharp safety box School health Train health workers on
up vaccination for vaccination mini media for Cold chain boxes care provider immunization in practice
and Status, especially education. EPI monitoring chart Appropriate venues for vaccination
immunization for Tetanus Educate on target Tally sheets, sessions in schools; Session plan for
vaccination in diseases for registration books vaccination;
girls vaccination in and reporting Supportive supervision from health
TT vaccination Ethiopia formats offices
for prevention of Educate on vaccines Recording, reporting performed
Tetanus in girls available for routine activities
Vaccinate for and supplemental
hepatitis B virus immunization
and other Strengthen
supplemental interpersonal
immunizations as communication on
recommended by vaccine schedule,
MoH appointment and
adverse events
following
immunization
6 Sexual and Counseling on Awareness creation IEC materials, HO/nurse Provide clinical assessment
reproductive prevention of on SRH issues, testing kits, Part time treatment, linkage and referral of
health services unwanted human rights and contraceptive doctors sexual and reproductive health cases
pregnancy, dual values, gender supplies psychologist to Adolescent and Youth Friendly
 89

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
protection and norms through mini Consent form services
contraception media Female and male Counseling and avail contraceptives
methods, Offering Availability of condom OCPs
HCG test. school based health Drugs depending on Inject able
Menstrual cycle service the standard Implants
management Peer education and Clearly prepared IUCD
Management of debating on SRH implementation Emergency contraceptives
dysmenorrhea issues guideline Condoms (female and male)
Counseling and Recording Pregnancy test (urine HCG test)
referral for sexual documentation and Counseling and referral for rape
violence and reporting survivors
cervical cancer
Establishment and
strengthening of
girls club on SRH
issues
7 HIV/STI Providing HIV Awareness Creation Clearly defined HO Provide clinical care and treatment
counseling, on HIV and STI implementation Nurses activities
testing and Peer Education guideline Psychologist Create referral linkage
referral services, Debating Registries and Nutritionist Monitor referrals
PICT Life Skill formats (part time) Develop tailored ICE/BCC materials
STI prevention, Youth Dialogue Thermometer (posters, fliers, brochures, billboards
diagnosis School community BP apparatus, and visual instructional Medias like
treatment and conversation Weight scale plasma etc.)
referral (treatment Training on the use Test kit Organize awareness creation events
using syndromic of male and female Drugs like WAD
approach) condom Job aids Adopt guiding manuals for PE, LS,
Referral to Comprehensive Guiding manuals for YD, SCC
VMMC, if Sexuality Education PE,LS,YD, SCC Select and train peer educators
desired, (CSE) ICE/BCC materials Conduct and monitor PE, LS, YD
Prevention of Mini media and club sessions
unintended materials Establish and run clubs, resource
pregnancy (dual Audio visual centers and mini-media activities
 90

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
protection) equipment materials Generate and transmit HIV/STI
Refer and ITC equipment prevention information through mini-
facilitate timely medias, radio,
entry to pre ART Provide tailored guidance and
and ART service counseling activities
Guidance and Provide tailored Psychosocial
Counseling support activities
Psychosocial
support
School clubs
Mini-media
service
Health resource
centers supported
whit IT
8 Mental health, Screening of Advocate to Data collection tools, Trained Nurse Develop policy/rules/code of conduct
substance use, mental illness, prohibiting licensing reporting formats Psychologist on substance use, violence
violence and disorders and risk business companies and referral forms Training materials/job aids/guideline
psychosocial factors in regarding to Job aids Conduct training for health care
support Screen students substances near to providers/teachers
for mental illness schools compound. Orientation for students/family/care
and disorders at Prohibit tobacco and givers
school entry alcohol advertising Advocacy to enforce the
annually in all school code/religious/community
Identifying premises leaders/government officials
students with risk Prepare content of information and
factors (social, design mobile applications
economic, Design web sites for key message
behavioral dissemination
problems) in the
class by teachers
Linking students
with the school
 91

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
health centers for
further assessment
and actions
Periodic screening
for illness and
disorders
integrated with
other health
screening
program.
Referral for
further psychiatric
treatment and/or
social supports
Prevention of
physical
punishment,
bullying,
harassment and
violence.
Follow up and
management of
substance use (use
of psychoactive
substances, khat,
alcohol, and
tobacco) and
violence in school
premises and
during all school-
sponsored:
prohibiting use of
psychoactive
 92

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
substances, khat,
alcohol, and
tobacco, shisha by
students and by
faculty and staff
on all school
premises and
during all school-
sponsored
activities.
9 Prevention of NCD, injuries and Advocate on Weight scale Nurse
NCDs and risk factors policies that support Height scale Home room
injuries prevention and healthy diets at Checklist for diet teacher and
control school and limit the diary assistant
availability of Pictures (Healthy
products high in food versus
salt, sugar and fats unhealthy food)
Prohibition of
promotions on soft
drinks, sweet and
foods which are risk
factors for obesity
Healthy dieting
(balanced calorie,
nutrient and fiber
consumption; water
consumption,
physical exercise,
Energy balance)
Importance of
consumption of a
variety of food items
Promote Physical Support schools to Safe field for playing Home room Encourage students to have at least
 93

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
activity and provide students Locally available teacher 25-30 minutes of moderate to
recreational with daily physical recreational facilities Sport Teacher intensity physical activity 3-5 days
activities, education and Adult supervisor per week at flag ceremony
Physical exercise should be equipped First aid kits Physical exercise and fitness
and fitness with appropriate Training manuals according to growth and devt, health
facilities and Lesson plan status of students.
equipment
Injury prevention Health education on Appropriate SBCC Teachers, Awareness raising of school
and care Injury prevention materials Guards community and parents on injury
and control Training manuals Health prevention
Awareness raising First aid kit, minor workers Advocacy for legislation and
activities to school injury treatment tools Psychologist regulation and enforcement---seat
community, students Community belt, helmet, zebra crossings
and parents on Assistants Conduct health education sessions
injury prevention Capacity building for school
strategies community on injury prevention and
Advocacy to ensure control
policies and Ensure safe school environment, play
legislations are in grounds etc.
place on injury Safe school buses, taxis, and
prevention and disciplined drivers
control
Treating minor
Injuries,
Referral linkage,
and
Rehabilitation/follo
w up Providing
training for health
workers
Care of NCDs in Diabetes education,
children with DM, counseling and care
Heart disease, Asthma education,
 94

SECONDARY EDUCATION [1st CYCLE (GRADE 9-10) & 2nd cycle (GRADE 11 -12)]
S. Packages Type of School Health Promotion and Material Resources Human Activities
No Health Service Communication Resources
Epilepsy, Cancer, counseling and care
Asthma Epilepsy education,
counseling and care
Cancer education,
counseling and care
Heart disease
education,
counseling and care
10 School health Aware school Education on flood, Fire extinguisher, Nurse Awareness raising of school
preparedness community about fire, conflict, Emergency foods community and parents on
and readiness possible drought, etc. emergency preparedness and
Addresses of
in education emergency types readiness
during organization ready to
Establish emergency team with the
emergency reposes during school community
emergency Screen for malnutrition and
dehydration link with nearby health
facility
Provision of micronutrient
supplements (such as vitamin A, iron
and iodine)
Provide psychosocial support
 95

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
1 SBCC and life SBCC Guiding manuals Health workers Developing psychosocial
skills Peer health Education, Age appropriate Teachers guidance
Guidance and SBCC materials Psychologist Providing guidance and
Counseling (flyers, audio counseling service that
Youth dialogue visual materials) maintains confidentiality,
School community privacy
conversation Adapt training curricula to
Promotion of health life train ToTs and (PEs )
style ToT for peer health
Promotion of voluntary educators
services /volunteerism Conduct, monitor and
support the peer education
Establish and strengthen
school health clubs
Establish mini-media and
edutainment committee
Conducting an Effective
Dialogue with students
(debate, panel discussion
etc.)
Strengthen 1 to 5 student
linkage
Develop/standardize health
education and promotion
messages, different SBCC
materials (posters, leaflets,
banners, billboards etc.
Education on adolescence,
biological and behavioral
changes related with age,
self-control & emotional
acts
Periodic forum for larger
 96

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
community
Establishment of different
clubs of music, drama, art
and dance clubs that
promote healthy life styles.
Design health message
with web page.
Mobile applications,
mobile text messages
Establish information
resource center
Strengthen existing library
service through provision
of life skill
Pre service training for
teachers at each level
Strengthen Voluntary
services (e.g., blood
donation)
Promotion of healthy
lifestyle including
prevention of
communicable and non-
communicable disease
Life skill Self-awareness Manuals, activity Teachers Develop / adapt life skill
Skills of knowing and Assertiveness, coping guides Health training manual for
living with one self with emotions, self- Teaching aids, Workers teacher, facilitators and
Skill of knowing and esteem, coping with audio visual and Psychologist club members to
living with others stress printed materials implement
Skills for making Empathy, effective Speaker (for Prepare age appropriate
effective decision communication, bigger events) and engaging life skill
Skills as a tool for nonviolent conflict activity guide for teacher,
making good leaders resolution, facilitators and club
 97

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Application of life skills negotiation, relating members to implement
in the world of work with others, managing Trainers (TOT) on life skill
peer relation ship facilitation
Creative thinking, Train and supervise the
critical thinking, facilitators and different
problem solving, club leaders
Decision making Conduct life skill sessions
Life skill as a tool for Follow-up and monitor
identifying sessions
alternatives of earning Build skills on
a living communication, critical
Life skill as a tool for thinking, managing
making successful emotions, negotiation,
entrepreneurs decision making, value
clarification, peer pressure
resistance
Assist students and club
leaders on periodic forums
(where experienced
speakers & role models
invited), Ted like
conferences, festivals on
different health topics for
larger community
 98

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
2 Nutrition Food and Nutrition Education/ promotion ICE/BCC Education and counseling
services Education and on diversity, balanced Food groups, food on diversity, balanced diet,
counseling diet, healthy dieting, pyramid, healthy dieting, food safety
food safety Nutrition canteen (food item selection,
Mobile app on menu processing, cooking and
healthy diet preservation/ storage
Establish nutrition club
Parental counseling
Celebration of national
nutrition day
Nutritional support for Awareness creation Case management Nutritional status
malnourished on prevention of guide line assessment and linkage for
malnutrition Antibiotic Supplements
Benefits of balanced
diet, diversification
and fortification
School gardening for Education on plot Vegetable seed Agriculturalist, Supply of seeds and
teaching easy method of preparation, crop Fruit seedlings trained teacher seedlings
food diversification for diversification, Plot for fruits and Avail plots
TVET cropping/ planting, vegetables Take home /Homestead
seed selection/ Water facility for gardening
nutrition sensitive irrigation
agroecology factors,
irrigation, use of
waste for
fertilization/soil
fertility, natural
resource
management,
economical use of
vegetable plot (Urban
agri), pest control
Promotion on
 99

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Homestead gardening
Supplementation (Iron Home based diet Nutrition supply
folate,) diversification (iron, folic acid)
Fortification of
products with
micronutrient
(industrial and home
fortification)
3 Water Personal hygiene IEC/BCC materials Infrastructures of Environmental Promotion of hands
sanitation and Health education and Software application toilets and urinals Health washing with soap or
hygiene promotion on topics of Mini media (isolated for male Or public substitute. (every critical
(WASH) personal hygiene and and female) Health officer time
utilization of toilets Hand-washing Regular washing of body
points hair and Combing hair,
cutting nails,
Brushing teeth,
Eye health, neatness of
dress and wearing
Mobile game Application
(WASH snake and ladders
board with dice or other
games)
Hand washing day
celebration
Fully integrated life skill
education focusing on key
hygiene behaviors and
using participatory
teaching techniques
Awareness creation of
Mosquito nets utilization
for boarding schools
 100

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Promotion of Provision of improved
appropriate utilization latrine within standard
and management of Awareness creation of the
latrine safe use of toilets and
urinals
Awareness creation and
promotion of appropriate
Anal cleansing material
Toilet day celebration
Water supply Demonstration water Provision of safe drinking
treatment chemical water
utilization Awareness creation
Drinking Water handling,
storage and utilization
Bathing areas
Food hygiene Students know how to
store food appropriately
and recognize common
signs of spoiled food
Medical checkup of food
handlers (depends on type
of school)
Inspection of food storage
and preparation areas
MHM service Quizzes Awareness creation
Conversations Menstrual hygiene
Focus group management (MHM)
dissection Promotion of sanitary pad
preparation using local
material
Fully equipped menstrual
hygiene management room
with necessary material
 101

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Occupational health IEC/BCC materials Different PPE Awareness creation of
Awareness creation occupational health hazard
using local media and safety rule
Danger sign indicator Risk area identification
poster Risk minimization method
Avail PPE for the school
community and educate
about how to utilized and
importance
Follow up of PPE
utilization
Considering all
infrastructures considered
disabled student
Solid and Liquid waste IEC/BCC materials Waste disposal site
management preparation
Greenery of the school Facilitate collection and
environment disposal of solid and liquid
Compound sanitation waste management
(putting dust pin in front of
classes, library, office)
Sanitation campaign
Construction and ready
waste management
sewerage lines, composting
areas and pits
Inspection of each
Classroom, workshops
areas and dormitory room
/areas cleanliness every
time
Avail plants for school
area greenery
 102

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Elimination of breeding
places of mosquitoes and
other insects
Hazardous waste IEC/BCC materials Awareness creation about
management/laboratory hazardous waste
settings/ Chemicals
E-waste
Ventilation of class Awareness creation of Monitoring the ventilation
rooms communicable states of class rooms,
disease (influenza, meeting hall and dormitory
TB, etc.) area
4 Management of Diagnosis of common Educate on First aid kit Teachers, Focused training of health
common outpatient diseases prevention of the (Plaster, gauze, Nurses workers on the common
diseases and Management of minor common diseases and cotton, iodine, Health officer diseases and care
disorders wounds and splint; early detection of alcohol, scissor, Part time Supportive supervision
Provide care on eye, ear signs and symptoms sutures) physician from health offices
and upper respiratory Utilize appropriate Snellen’s chart Recording and reporting of
tract infections models to Oral and teeth routine services
Provide dental care demonstrate care model for
Referral services Strengthen demonstration of
interpersonal teeth brushing
communication Otoscope
during encounters Essential
equipment and
drug list (Annex)
 103

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
5 Routine catch Routine screening for Educate on target Vaccine carrier as Teachers and Train health workers on
up and vaccination status, diseases for available. HWs immunization in practice
Immunization especially for Tetanus vaccination in Cold boxes Supportive supervision
Program Vaccinate for hepatitis B Ethiopia Safety boxes from health offices
virus Educate on vaccines EPI monitoring Recording and reporting of
And other supplemental available for routine chart routine and supplemental
Immunizations as and supplemental Tally sheets, vaccination services
recommended by MoH immunization registration books
Strengthen and reporting
interpersonal formats
communication on
vaccine schedule,
appointment and
adverse events
following
immunization
6 Sexual and Counseling and Awareness creation Implementation HO/nurse, lab Develop tailored SBCC
reproductive provision of services for about SRH issues guideline tech materials
health services prevention of unwanted Promote abstinence IEC materials, Doctor Offer counsel and avail
pregnancy, on the use Education on safe sex testing kits, Psychologist contraceptives
dual protection and practice contraceptive Nutritionist OCPs
contraception options Condom promotion (OCP, ECs, Injectable
including long acting (female and male) implants, IUD Implants and IUDs
methods, Offering HCG Education on unsafe including Emergency contraceptives
test abortion, HTP condoms and Condoms (male and
Menstrual cycle Create a plat form for LARCs ) supplies female)
management young people to Vaccines Pregnancy test (urine HCG
Management of enable them change Documentation & test)
dysmenorrhea agents in the service recording Diagnosis and treatment of
cervical cancer provision. (e.g., materials STIs (genital ulcer,
screening, treatment and debate, m-health, virginal and urethral
referral social media, m- discharges, inguinal bubo,
Establishment and health) scrotal swelling and PID
 104

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
strengthening of girls CSE Dx and Rx of menstrual
club on SRH issues disorders,
Diagnosis and treatment comprehensive abortion
Comprehensive abortion care service
care Counseling and
ANC counseling and management of rape
referral survivors
Cervical cancer
screening and referral
Provide comprehensive
abortion care and
referral linkage
Sexual violence Dx, Rx
and referral
Mentoring and coaching
using peer to peer
approach newly enrolled
students
7 HIV/STI Providing HIV Peer education For Services Provide clinical care and
counseling and testing Life skill Registries and treatment activities
services, Youth dialogue formats Create referral linkage
PICT School community Thermometer Monitor referrals
STI/HIV prevention, conversation BP apparatus, Develop tailored ICE/BCC
diagnosis and treatment Awareness creation Weight scale materials (posters, fliers,
(Syndromic Approach), on HIV and STI VCT room brochures, billboards etc.)
Referral to VMMC, if Test kit Organize awareness
desired, Drugs creation events
Prevention of Job aids Adopt guiding manuals for
unintended pregnancy For SBCC PE, LS, YD, SCC
(Dual Protection) Guiding manuals Select and train peer
Refer and facilitate for PE,LS,YD, educators
timely entry to pre ART SCC Conduct and monitor
and ART service and PE,LS,YD sessions
 105

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Health Resource Centers ICE/BCC Generate and transmit
supported with IT materials HIV/STI prevention
Referral and linkage for ITC equipment information through mini-
ART service to the M- Health medias, radio, mobile
nearby Health center Audio-visual phone, internet
learning materials Provide tailored guidance
CSE (age cultural and counseling service
appropriate) Train mentors and provide
coaching activities
Train providers on
Adolescent/youth friendly
service
8 Mental health, Screening of mental Advocate to Data collection Trained nurse Develop policy/rules/code
substance use, illness, disorders and prohibiting licensing tools, reporting Psychiatric of conduct on substance
violence and risk factors business companies in formats and /psychologist use, violence
psychosocial Screen students for regarding to referral forms Training materials/job
support mental illness and substances near to Job aids aids/guideline
disorders at school entry schools compound Conduct training for
annually Prohibit tobacco and Health care
Identifying students with alcohol advertising in providers/teachers
risk factors (social, all school premises Orientation for
economic, behavioral students/family/care givers
problems) in the class by Advocacy to enforce the
teachers code/religious/community
linking students with leaders/government
the school health centers officials
for further assessment Prepare content of
and actions information and design
Periodic screening for mobile applications
illness and disorders Design web sites for key
integrated with other message dissemination
health-screening
program
 106

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Referral for further
psychiatric treatment
and/or social supports
Prevention of physical
punishment, bullying,
harassment and violence
Follow up and
management of
substance use (use of
psychoactive substances,
khat, alcohol, and
tobacco) and violence in
school premises and
during all school-
sponsored activities
9 Prevention of Adoption of healthy Advocate on policies Weight scale Nurse Weight, Height and BMI
NCDs and dietary habits that support healthy Height scale Home room assessment
injuries diets at school and Checklist for diet teacher and Blood pressure screening
limit the availability diary assistant Dietary habit assessment
of products high in BP apparatus Advise and counseling on
salt, sugar and fats Pictures (Healthy healthy diet
prohibition of food versus Check lunch boxes for
promotions on soft unhealthy food) hygiene, quantity, quality
drinks, sweet and and variety of foods and
foods which are risk drinks
factors for obesity Educating students about
Healthy dieting what is good and bad food
(balanced calorie, and drink
nutrient and fiber Screening for Tobacco,
consumption; water alcohol and khat use
consumption, Brief interventions for
physical exercise, those who use alcohol or
Energy balance) tobacco
 107

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Importance of
consumption of a
variety of food items
Promote physical Schools are Safe field for Home room Encourage children to have
activity and recreational encouraged to provide playing teacher at least 30-40 minutes of
activities to do students with daily Locally available Sport Teacher moderate to intensity
Physical exercise and physical education recreational Nurse supports physical activity 3-5 days
fitness and should be facilities and tools per week at in off
equipped with First aid kit academics periods
appropriate facilities Training manuals Physical exercise and
and equipment Lesson plans fitness according to growth
and devt, health status of
students.

Injury prevention and Health education on Appropriate Teachers Awareness raising of

care Injury prevention and SBCC materials Guards school community and
control Training manuals Health workers parents on injury
awareness raising Psychologist prevention
activities to school Community Advocacy for Legislation
community , students and regulation and
and parents on injury enforcement---seat belt,
prevention strategies helmet, zebra crossings
Advocacy to Ensure Conduct health education
policies and sessions
legislations are in Capacity building for
place on injury school community on
prevention and injury prevention and
control control
Ensure safe school
environment, play grounds
Safe school buses, taxis,
and disciplined drivers
 108

TERTIARY LEVEL (TVET, College, and Universities)

S. Packages Type of School Health Health Promotion and Material Resources Human Activities
No Service Communication Resources
Care of NCDs (Children Diabetes education,
and adolescents NCDs Counseling and care
(with DM, Heart Asthma education,
disease, Epilepsy, counseling and care
Cancer, Asthma) Epilepsy education,
counseling and care
Cancer education,
counseling and care
Heart disease
education, counseling
and care
10 School health Aware school Education on flood, Fire extinguisher, Nurse/ HO/ Awareness raising of
preparedness, community about fire, conflict, drought, Emergency foods physician. school community and
response and possible emergency etc. parents on ways and means
Addresses of
recovery in types of protecting themselves
organization
education during emergency
ready to reposes
during Establish emergency team
during emergency
emergency with the school community
Screen for malnutrition and
dehydration link with
nearby health facility
Provision of micronutrient
supplements (such as
vitamin A, iron and iodine)
Provide psychosocial
support
 109

Annex VI: M & E Indicators for SHP

Indicator calculation Data
Source of
Indicator Indicator definition collection Remark
information
Numerator Denominator frequency

Percentage of schools with Proportion of all schools with Schools with All schools EIMS/HMIS Annually Disaggregated
minimum school health minimum package of school minimum school by level
packages health package. Minimum health package (primary,
package means providing 10 secondary,
school health packages tertiary)

Percentage of students who Proportion of students who Number of students Total number of EIMS/HMIS Biannually Disaggregated
received deworming drug received the deworming drug who received eligible students by school level
deworming drug for deworming (preschool and
primary
school)

Percentage of school students Proportion of school students Number of students Total number of EIMS/HMIS Annually Disaggregated
who obtained visual screening who obtained visual screening who received annual students by school
at the beginning of the school visual screening
year

Percentage of school students Proportion of school students Number of students Total number of EIMS/HMIS Annually Disaggregated
who obtained hearing defect who obtained hearing who received annual students enrolled by school
screening. screening at the beginning of hearing screening per grade
the school year

Percentage of students who Proportion of students who Number of students Total number of Survey Every three Disaggregated
correctly demonstrate proper correctly demonstrate proper who correctly students years by grade of
tooth brushing. tooth brushing. demonstrate proper enrollment
tooth brushing.

Percent of students sleeping The proportion of students Number of students Total number of Survey Every three Disaggregated
under an ITN the previous night who were sleeping under an who were sleeping students years by school
ITN the previous night of the under an ITN
assessment.
 110

Percentage of schools Proportion of schools Number of schools Total number of Survey Annually
implementing screening implementing screening implementing schools
vaccination status of students at vaccination status of students screening vaccination
enrollment at enrollment status of students at
enrollment

Percentage of fully immunized Proportion of fully immunized Number of fully Total number of Survey Annually Disaggregated
preschool students preschool students immunized preschool preschool by grade
students students

Percentage of students screened Proportion students screened Number of students Total students HMIS/EMIS Quarterly Disaggregated
for malnutrition for malnutrition screened for screened for by age
malnutrition malnutrition

Percentage of malnourished Proportion of malnourished Number of Total number of Disaggregated

students managed students managed malnourished students by age
students managed screened

Percentage of schools providing Proportion of schools Number of schools Total Number of HMIS/EMIS Quarterly
nutritional counseling services providing nutritional providing nutritional schools
counseling services counseling services

Percentage of students who Proportion of students who Number of students Total number of Survey Annually
reported having improved their reported having improved who reported having students
diet and life style their diet and life style improved their diet
and life style

Percentage of schools with Proportion of schools with Number of schools Total number of EMIS Quarterly
school gardening service school gardening service with school schools
gardening service

Percentage of schools with Proportion of schools with Number of schools Total number of EMIS Quarterly
school cooking demonstration school cooking demonstration with school cooking schools
session session demonstration
session
 111

Percentage of students Proportion of students Number of students Total number of HMIS/EMIS Bi annually
supplemented with Vitamin A supplemented with Vitamin A supplemented with students eligible
Vitamin A for Vit A

Percentage of students screened Proportion of students Number of students Total number of HMIS/EMIS Annually
for MNS risk factors screened for MNS risk factors screened for MNS students
risk factors

Percentage of schools with safe Proportion of schools with Number of schools Total number of Admin Annually Inspection
school environment safe school environment with safe school schools
environment

Percentage of students taught Proportion of students taught Number of students Total number of Survey Annually
about injury prevention and about injury prevention and taught about injury students
safety safety prevention and safety

Percentage of young people Proportion of students aged 15 Number of students Total number of Survey Every 3
aged 15 to 24 years, who have to 24 years, who have had 15 to 24 years, who students aged 15 year
had sexual intercourse before sexual intercourse before the have had sexual to 24
the age of 15 years. age of 15 years. intercourse before the
age of 15 years.

Percentage of students who Proportion of students who Number of students Total number of Survey Every 3
used a condom the last time used a condom the last time who used a condom sexually active years
they had intercourse. they had intercourse. the last time they had students
intercourse.

Percentage of students who are Proportion of students who Number of students Total number of Survey
using contraceptive used modern contraception who are using sexually active
contraceptive students

Percentage of schools with Proportion of schools with Number of schools Total number of Assessment
functional school health club functional school health clubs with functional in the schools
(definition to be defined) school health club
 112

Percentage of students with a Proportion of students with a Number of students Total number of Disaggregated
specific attitude specific attitude with a specific students by package
(favorable/unfavorable) (favorable/unfavorable) attitude(favorable/unf
towards a recommended towards a recommended avorable) towards a
behavior behavior recommended
behavior

Percentage of students Proportion of students Number of students Total number of HMIS Quarterly
participated in school participated in school participated in school students
community conversation community conversation community
sessions. sessions. conversation
sessions.

Percentage of model students Proportion of model students Number of model Total number of HMIS Quarterly
on health according to model student students students
criteria

Percentage of students who Proportion of students who Number of students Total number of Survey Disaggregated
received health messages received health messages who received health students by source
messages

Percentage of schools Proportion of schools Number of schools Total number of Annually

participated on community participated on community participated on schools
outreach activity outreach activity community outreach
activity

Percentage of students who Proportion of students who Number of Students Total number of HMIS/EMIS Quarterly Disaggregated
received training on life skills received training in life skill who received training students by level
sessions in life skill (primary,
secondary,
tertiary)

Percentage of teachers who Proportion of teachers who Number of teachers Total number of HMIS/EMIS Quarterly Disaggregated
received training of trainer on received training of trainer in who received teachers by level
life skills life skill sessions training of trainer in (primary,
life skill secondary,
tertiary)
 113

Percentage of students who Proportion of students who Number of students Total number of Survey Every three
mentioned at least three mentioned at least three who mentioned at skills years
essential life skills essential life skills least three essential
life skills

Percentage of schools with Proportion of schools with Number of schools Total number of Admin report Quarterly
functional hand washing functional hand washing with functional hand schools
facilities facilities washing facilities

Percentage of school with Proportion of school with Number of school Total number of HMIS/EMIS Annually
functional latrine facility as per functional latrine facility as with access to schools
the national standard per the national standard functional latrine
(functional to be defined) facility as per the
national standard

Percentage of schools with safe Proportion of schools with Number of schools Total number of Admin report Annually
drinking water as per the safe drinking water as per the with safe drinking schools
national standard national standard water as per the
national standard

Percentage of students who Proportion of students who Number of students Total number of Survey Every three
demonstrated good hygiene demonstrated good hygiene who demonstrated students years
practices (including MHM) practices good hygiene
practices

Percentage of schools with Percentage of schools with Number of schools Total number of Survey Annually
proper solid waste disposal proper solid waste disposal with proper solid schools
facility facility waste disposal
facility
 114

Annex VII: Stakeholder Analysis

Stakeholders Behaviors Desired Their Needs Their Institutional response
Influence
Students Active participation and Quality health service Engaging students from planning to
utilize the services Friendly service implementation
Be a change agent Safe and conducive environment Conduct student need assessment
Peer educator Better protected from health risks High Friendly service
Healthy behaviors and Confidential service Quality improvement and quality
actions Entertainment assurance
Train service providers on
Develop code of conduct
Respect local values and beliefs

Woreda Ownership of the program Positive result from the program Strong advocacy
admin Resource allocation Available and functional service Engagement
Monitor, support and Quality health service High
follow up Behavioral change from students
Community mobilization

Teachers and Cooperative and Smooth teaching-learning process Engaging teachers from planning to
admin staff participatory Well performing students implementation
Ownership of the program Behavioral change from students Awareness creation on the impact of
To be champions of the To get health service from the High the program on students’ performance
program students’ health center Design the service to include the needs
Safe and conducive environment of teachers
Align the students’ health program
with the learning-teaching process of
the school.
Parents/Care Cooperative and Well performing students Awareness creation about the program
takers participatory Safe school environment Involving parents
Positive attitude to the Healthy behaviors and actions High Create platforms for regular discussion
program Healthy development with parents
Good parenting
Support family activity
(labor demand)
 115

Students’ Respectful, compassionate Continuous training Design incentive packages

health center and caring Career development Orientation and training
staff Competent Incentives Develop code of conduct
To be confidential Supportive supervision High Conduct regular supervision
Proactive Regular follow up Avail essential equipment and supplies
Conducive working environment as per standard
Job aids/
guidelines/manuals/reporting formats
Local health Smooth referral linkage Smooth referral linkage Orientation and consensus building to
facility Technical and logistics Report for the students’ health center clarify the objective of the program
(Hospital, and supply support Supportive supervision High and the role of the health facility
Health center, Provide outreach service Regular follow up Training
HEWs) Train students’ health Training Regular follow up and supervision
center staff Job aids Avail job aids

NGOs/FBOs Harmonization Involvement Engaging NGOs

Technical and financial Evidence based interventions Medium Conduct partners mapping
support Plan aliment
Education Ownership Smooth teaching-learning process Advocate for ownership of the
sector Collaboration Well performing students program by the education sector
Resource allocation Behavioral change from students High Work with MOE from program
Safe and conducive learning design to evaluation
environment
Water sector Collaboration Improved access to safe water Advocate for ownership of the
Improved access to safe Collaboration program by the education sector
water in schools High Work with MOE from program
Resource allocation design to evaluation
 116

Annex VIII: Detail program costs

T ABLE 6 SHP COSTS BY CATEGORY
Year 1 Year 2 Year 3 Year 4+* Total
Total (ETB) 2,239,876,809 3,067,055,466 4,027,589,562 2,374,543,080 11,709,064,915
Administrative 7,000,000 2,146,000 2,302,658 2,470,752 13,919,410
Equipment 226,550,517 243,559,859 261,845,278 1,627,361 733,583,015
Supplies 288,147,748 617,651,602 993,727,479 1,065,449,102 2,964,975,932
Drugs 30,348,936 65,128,818 104,824,832 112,477,045 312,779,631
Training + Salary 356,582,392 710,140,925 1,132,185,791 1,192,518,820 3,391,427,928
Infrastructure 1,331,247,215 1,428,428,261 1,532,703,524 - 4,292,379,000

T ABLE 7 SHP COSTS BY S CHOOL LEVEL AND T YPE

Year 1 Year 2 Year 3 Year 4+* Total
Total (ETB) 2,239,876,809 3,067,055,466 4,027,589,562 2,374,543,080 11,709,064,915
Total Fixed 1,597,387,661 1,691,141,733 1,814,595,079 - 5,103,124,472
Total Recurrent 642,489,148 1,375,913,733 2,212,994,482 2,374,543,080 6,605,940,443

Total National Level 7,686,895 2,867,153 3,076,455 3,301,036 16,931,538

Fixed 5,014,805 - - - 5,014,805
Recurrent 2,672,090 2,867,153 3,076,455 3,301,036 11,916,733

Total Regional Level 16,286,270 826 887 951 16,288,934

Fixed 16,285,500 - - - 16,285,500
Recurrent 770 826 887 951 3,434

Total Pre-schools 113,473,370 193,424,481 284,443,754 247,538,801 838,880,406

Fixed 46,681,614 50,089,372 53,745,896 - 150,516,883
Recurrent 66,791,756 143,335,109 230,697,857 247,538,801 688,363,523

Total Primary Schools 1,870,446,134 2,508,160,631 3,229,013,836 1,731,041,327 9,338,661,928

Fixed 1,403,370,711 1,505,816,773 1,615,741,398 - 4,524,928,883
Recurrent 467,075,423 1,002,343,857 1,613,272,439 1,731,041,327 4,813,733,046

Total Secondary
173,621,649 246,815,938 329,771,364 209,034,979
Schools 959,243,930
Fixed 117,219,124 125,776,121 134,957,777 - 377,953,022
Recurrent 56,402,525 121,039,818 194,813,587 209,034,979 581,290,908

Total Tertiary Level 58,362,490 115,786,437 181,283,266 183,625,986 539,058,179

Fixed 8,815,905 9,459,467 10,150,008 - 28,425,380
Recurrent 49,546,584 106,326,970 171,133,258 183,625,986 510,632,799
*Year 4 costs represent the yearly recurrent cost of the SHP following full roll out
 117

T ABLE 8 SHP AVERAGE COST OF SERVICE PER SCHOOL AND PER STUDENT BY COST
CATEGORY (ETB)

Pre-primary Primary Secondary Tertiary

Per Per Per Per Per Per Per Per
Cost Category School Student School Student School Student School Student
Shared Cost 328,396 378.55 418,396 709.30 438,697 533.41 145,740 118.01
1. SBCC 6,522 7.52 5,015 8.50 21,736 26.43 - -
2. Nutrition 9,286 10.70 7,474 12.67 1,840 2.24 497 0.40
3. WASH 4,655 5.37 4,477 7.59 4,826 5.87 - -
4. Common
5,766 6.65 2,735 4.64 4,304 5.23 4,773 3.87
Diseases
5. Vaccination 1,511 1.74 1,455 2.47 1,502 1.83 1,584 1.28
6. SRH - - 2,683 4.55 184 0.22 1,622 1.31
7. HIV&STI - - 884 1.50 880 1.07 1,404 1.14
8. MNS Disorders 170 0.20 170 0.29 170 0.21 170 0.14
9. NCDs 1,753 2.02 1,614 2.74 1,731 2.10 2,437 1.97
10. Emergency
- - - 438,697 - - -
Preparedness
Total 358,062 412.74 444,909 754.25 475,874 578.61 158,230 128.12