Introduction

Schools play a defining role in making safe, nurturing environments available that lay the foundation for the children to develop, become healthy, learned and engaged citizens [1]. The Indian school system is one of the largest in the world, catering to over 25 crore children through a network of 15 lakh schools staffed by over 85 lakh teachers [2]. As children spend between 800–1,000 h annually in schools [3], the schools become a crucial social and physical environment second only to homes, and their strategic potential from a public health perspective can be leveraged further. Schools provide a relatively controlled environment as compared to homes, making it possible to systematically implement interventions with sustained impact for over 12 y on children during their developmental period [4]. The health habits formed during early childhood and adolescent periods are likely to be sustained for the rest of the life [5]. In this backdrop, choosing schools as platforms for promotive and preventive healthcare interventions has globally been adopted as a strategy. Healthy children also do better academically; therefore, school health services help fulfil the overall goal of the education sector and results in a high return on investment [6]. Empowered children act as change agents at scale by influencing their families and communities, thus resulting in changing social norms and creating resilient and prosperous communities [6]. Globally, the approach of health-promoting school (HPS) has been advocated [7]. India initiated the school health program more than a century ago, the inherent potential of the program to nurture adolescent well-being have remained largely underutilised and thus with immense scope to be strengthened. This review provides historical evolution of school health programs (SHP) in India, analyses status and challenges in school health services and provides a way forward strengthening them to promote well-being among adolescents.

Material and Methods

A review of literature on school health services through government initiatives in India was conducted. The literature included the review articles published in the last 30 y on School health programs in India, a few articles published for other low- and middle-income countries (LMICs), implementation guidelines and evaluation reports by state governments in India wherever available, guidelines and evaluation reports published by UN agencies on school health, and opinion pieces by experts. The major focus was on implementation strategies and the overall model of school health programs.

School Health Services in India

The first known health program in India was launched in 1909 in the erstwhile Baroda province in British India [8]. Key milestones of school health initiatives in India are provided in Supplementary Fig. S1. However, most of these school health program remained low profile and there has been limited impacts of these school health program.

In the last decade, atleast three key programs have been launched with school health components: Rashtriya Bal Swasthya Karyakram (RBSK), Rashtriya Kishor Swasthya Karyakram (RKSK) and Ayushman Bharat School Health Program (SHP-AB) (Table 1) [9,10,11]. However, even these programs have had implementation issues and most of the envisaged interventions have not been translated into actual implementation [12,13,14]. One of the key challenges is that the intersectoral coordination is found to be wanting with current programs primarily being driven by the health sector with minimal stake from the education sector. The programs are implemented through a transactional top-down approach with nominal efforts to meaningfully engage the adolescents to empower and enable them to act for their own well-being. The programmatic interventions have primarily been limited to piecemeal health screening without focusing on the holistic overall development of children and their well-being. There is minimal involvement of the teachers, parents/caregivers or the community. Not much emphasis or efforts have been put into enhancing the health literacy or connectedness among the adolescents or for meaningfully engaging them in the planning, implementation and evaluation of the school health programs [15,16,17]. The SHP-AB is limited to government aided schools. However, nearly 50% of total students in India are enrolled in the private unaided school [18]. In recent years many profit and not-for-profit organisations are offering paid school health services but are mainly limited to schools charging very high fees to students thus reaching to the upper socio-economic section of the society. The gap analysis of three school health programs done with reference to the three assessment indicators namely —Service delivery, Governance mechanisms and Accountability, research, monitoring and evaluation is provided in Box 1 [12, 13, 19,20,21,22,23].

Table 1 Salient features of existing three major school health programs in India
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Health-Promoting School and the SHP in India

The current global strategy for SHP focused on health-promoting school (Box 2) [7, 24,25,26]. The HPS approach including the whole-school approaches to health have been associated with considerable improvements in learning, health, nutrition, functioning and well-being of students. The HPS services should be extended to teachers and parents for adopting healthy lifestyles by focusing on health literacy to create an enabling environment at homes and schools to adopt healthy lifestyles. An evaluation of the HPS supports the key elements of the HPS approach and confirms that school health interventions are most effective when they are sustained (long-term interventions), multifactorial (i.e., adapting comprehensive approach), adapt a whole school approach and involve appropriate training at different levels of implementation. Under the Ayushman Bharat School Health Program (SHP-AB), school teachers are supposed to work as health ambassadors and are going to be the first contact point for health promotion activities for students. In this scenario, it becomes very important that teachers adopt healthy lifestyles and can act as role models to school children. There is also adequate evidence to suggest that, without ownership of the education department, school health programs cannot be sustained [25] and thus the Education department should be the primary stakeholder for school health by including age-appropriate health education and life skills education as part of curriculum. School health could be an important platform and stage of life for an individual to receive health literacy interventions also including other global concerns like climate change and gender sensitivity. A recent review report for making every school a health promoting school highlighted the seven common enablers and three barriers to HPS (Table 2) [7, 25]. SHP-AB program document has a component of teacher training and involvement of the education sector, however, the process for local community involvement is missing for planning and implementation. Similarly, it also lacks different strategies/ scope of flexibility for rural–urban context and alternative strategy in view of existing health workforce shortage.

Table 2 Enablers and barriers to health-promoting schools [25]
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Based on success stories of other neighbouring LMICs, there are several lessons that can be adapted in terms of strengthening school health services as specified in Table 3 [27,28,29,30,31,32,33]. The study of factors from these success stories are the very areas that have emerged as lacunae in the appraisal of school health programs in India namely, lack of integration/convergence, community engagement, monitoring/evaluation and research and flexibility for local adaptation.

Table 3 Highlights from school health programs in other LMICs [27, 28] and Indian states
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Discussion

There are many global learnings about strengthening school health programs. An inter-agency framework called FRESH — an acronym for Focusing Resources on Effective School Health- first published by United Nations Educational, Scientific and Cultural Organization (UNESCO), United Nations Children's Fund (UNICEF), the World Health Organization (WHO) and the World Bank in 2000 is widely recommended for school health services [34]. The FRESH framework proposes four essential components to guide all school-based and school-linked health activities: (a) formal policies that support child health and development; (b) skills based health education which expands to include co-curricular and non-formal activities; (c) a defined set of basic, scalable services to support educational success, health and development; and (d) a suitable physical environment and a positive psycho-social environment which encourages student, parent and community involvement. The FRESH framework further includes several cross-cutting themes to deliver the infrastructure, out of which the originally identified three themes were effective partnerships, community ownership and child/youth participation.

The WHO guideline proposes seven broad health areas for school health services: positive health and development; unintentional injury; violence; sexual and reproductive health, including HIV; communicable disease; non-communicable disease, sensory functions, physical disability, oral health, nutrition and physical activity; and mental health, substance use and self-harm [35, 36]. WHO guidelines focus on the need for moving away from narrowly focused interventions, and towards Comprehensive School Health Services, which are defined as interventions that address at least four out of the seven defined areas. Additionally, WHO advocates for designing school health services based on local needs assessment, and having components of health promotion, health education, and screening leading to care and/or referral as appropriate [36].

Way Forward for India

One of the reasons for sub optimal school health programs — not only in India but also in most low- and middle-income countries — is, arguably, limited understanding and clarity on what constitutes well-functioning and effective school health services. This situation co-exists in spite of evidence-based guidelines and success stories. The monitoring, research and evaluation of existing school health services need to be strengthened and built-into the school health program design and possibility of using technologically enabled Monitoring and Evaluation (M-&-E) so that every state can periodically review the status of their SHP uniformly. Based on the evaluations, revamping of SHP can be designed.

Second, a dedicated budgetary allocation for school health programs with a predetermined plan to use the allotted funds optimally needs to be focused upon. Third, various community-based organisations, non-governmental organizations (NGOs) should be considered as important stakeholders for planning and implementation of School Health Services (SHS). Engaging communities and families have proven to improve the effectiveness of SHPs, with intergenerational school programs rapidly gaining popularity across the world. Crucial benefits that shall further the objectives of the existing school health program are: More active involvement of whole families (including parents) for children’s academic achievement & enrichment, physical, cognitive, & mental health and also impacting societies at large [37,38,39].

The government SHPs primarily serve government and government-aided schools, largely leaving out private schools. Considering that the government SHSs provide a plethora of services, going way beyond curative and emergency services, all children, regardless of the type of school, rightfully deserve to be provided these service [40,41,42,43].

The delivery of SHP should be multipronged, and the Education department should play a major role with active involvement of teachers to ensure better sustainability of the program. This should include curriculum enrichment, role-modelling and enabling environment for health promotion and wellbeing moving beyond traditional health service centric school health program to comprehensive school health program.

To leverage the favourable demographic dividend of India and to ensure that the coming decades do not become a “missed opportunity”, it is crucial to systematically identify the lacunae in the existing SHPs, adapt the evidence-based frameworks to fill in the lacunae, and utilise the available resources for building a generation of healthy and educated children. India has to embrace the principles of Comprehensive school health initiatives with Global framework like Health promoting school strategies but to yield maximum benefits it needs to be sensitive to cultural context and diversity and inequity for a wide spectrum including socioeconomic benefits for the present and future generations of the country, in line with attainment of the Sustainable Development Goals (SDG) [44, 45]. If designed and implemented effectively, school health initiatives can truly stand out as futuristic interventions, nurturing and empowering children today to create agents of change for tomorrow.

Conclusions

The school health program in India needs to move beyond the screening centric approach and be aspirational and holistic in nature focusing upon the overall well-being of the adolescents. Concerted efforts through intersectoral convergence are needed to optimally utilise the platforms of schools for promotion of adolescent well-being. The learnings from the past, from the Indian states and other low- and middle-income countries should be used for effective implementations.