The Grand Convergence – Addressing Health and Education Together to Accelerate Progress The 1993 World Development Report (WDR) was the first major health report targeted at finance ministers – arguing persuasively that targeted health expenditures were not a drain on the economy, but rather an investment in prosperity.1 In December 2013, prompted by the 20th anniversary of the 1993 WDR, The Lancet Commission on Investing in Health was created to revisit the recommendations of 1993. The Commission confirmed that health investments have accounted for 24% of economic growth between 2000 and 2011 and further modeling suggested that by 2035 nearly all countries could achieve a ‘Grand Convergence’ and reduce their infectious, maternal and child mortality rates to those of the best-performing middle-income countries.2
16-8-4-0. Expressed quantitatively, this ‘Grand Convergence’ pointed to the opportunity to reduce the under-five child deaths to 16 per 1,000 (from an average of 48 per 1,000); reduce the annual AIDS death rate to 8 per 100,000 (from an average of 25 per 100,000); and reduce the annual tuberculosis death rate to 4 per 100,000 (from an average of 14 per 100,000).3 Shorthand for this ambition is 16-8-4.4 The Commission’s comprehensive report firmly acknowledges that improvements beyond health – in social and intersectoral areas including education – are central to achieving long term health gains5 noting in particular that ‘improved education is a powerful mechanism of income growth’ and that ‘healthier children are more likely to attend school and have greater cognitive capacity for learning.’6 However, the report notes that gains in these areas can be impeded by complex and entrenched political issues and concludes that making direct investments in the health sector is the most expedient way to address health outcomes.7 The strong relationship between health and education however, makes tackling these political issues and this added layer of complexity, imperative. The ambitious health convergence will not only be bolstered by concurrent gains in education, sustainable progress, particularly for girls and the most vulnerable, will be increasingly difficult without also addressing lack of access to a quality education. As The Lancet Report notes, half of the health improvements between 1960 and 1990 in low and middle-income countries were from changes in income and education.8 The evidence of the health and economic benefits in the short and long term from education should be more explicitly factored into the Grand Convergence on health with a representation of the acceptable number of children who should be excluded from at least a basic education. That number is zero. Zero children out of school by 2015. Shorthand for this ambition is 16-8-4-0.
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Education and Health – Converging Approaches Why address health and education together? The success of health interventions is dependent on the ability of individuals and communities to translate information and knowledge of disease prevention and symptoms into their daily living. For women in particular, equal opportunity is determined by access to education as well as health services and information, particularly in the years before and during adolescence. The evidence of the impact of education on health outcomes is clear:
A child born to literate mother is 50% more likely to survive past the age of five than a child born to an illiterate mother.9 Educated mothers are better informed about specific preventable diseases such as diarrhoea, pneumonia, and malaria, leading killers of children.10 In 2012 alone, 6.6 million children under five died of preventable causes in lower and lower middleincome countries. At least, 15% of these deaths could have been prevented if all women in these countries completed primary education – a million children every year. If all women in these countries completed secondary education, under five-deaths would fall by 49% – 3 million young lives.11 Evidence shows that investments in education clearly contribute to better health outcomes. Education equips individuals and communities with essential skills to effectively use health care services and individuals with an education are better informed about diseases, take preventative measures, recognize illnesses early and tend to use health care services proactively.12 Education has a great impact on sexual and reproductive health outcomes for girls and women. In many countries in sub-Saharan Africa, the birth rate among girls with no education is over four times higher (207 per 1,000) than those with secondary education (48 per 1,000).13
Access to quality learning for especially for girls, means they can better invest in their own health and the health and education of their children. Specific impacts of education on health outcomes also include:
Infectious Diseases HIV/AIDS Youth and women are at higher risk for contracting HIV, but education provides the space and tools for women and young people to learn about risky behaviors14 and how to negotiate and practice safer sex.15
Education increases awareness about HIV prevention. At least 85% of literate women in sub-Saharan Africa knew where to get tested compared to 52% of illiterate women; 91% of literate women know that HIV is not transmitted through sharing food, compared to 72% of illiterate women.16 Girls with primary education are significantly less likely to contract HIV. Evidence shows that when girls stay in school through secondary education, the protective effect against HIV is significant. HIV risk is lower; there is more condom use and fewer sexual partners and subsequent reduced rates of transmission.17 A cash transfer intervention targeting young women in Malawi that provided US$10/month conditional on satisfactory school attendance (plus payment of secondary school fees) to current schoolgirls and
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recent dropouts to stay in or return to school led to significant declines in early marriage, teenage pregnancy, and self-reported sexual activity among program beneficiaries after just one year of program implementation.18 Tuberculosis At least 300,000 children drop out each year in India because they are infected with TB or need to take care of an infected family member.19 Efforts to prevent and cure TB are an essential element in improving learning for children, and preventing children from engaging in hazardous work.
When a parent falls ill with TB and can no longer work, children may be forced to drop out of school and join the workforce to provide for the family and make up for lost economic opportunity. A study of 167 Indian parents with TB showed that 15% had children drop out of school and 34% could no longer afford schoolbooks for their children.20 Despite TB no longer being contagious after 2-3 weeks of treatment, most schools in China require students to be completely cured before returning to school – a minimum of six months.21 Simple educational interventions can impact knowledge and treatment about TB. A study conducted in India shows improving the knowledge and awareness about TB in schoolchildren spreads awareness and leads to significant changes in perception of disease and treatment among the wider population.22 Education of school children is also a significant method of disseminating health information to parents who are illiterate.
Malaria Malaria is one of the leading causes of death in children under five.23 Malaria in pregnant women can affect the development of the unborn child; increase children’s susceptibility to other illnesses; and reduce income available for schooling.24 The evidence demonstrates that those with education are far more likely to use bednets properly, be aware of the symptoms and know when and how to seek treatment.
Because of the direct links between education and the likelihood of preventative measures, Malaria Indicator Surveys in 7 African countries revealed that the odds of children carrying malaria parasites was 44% lower if the mother had secondary education.25 Approximately 40% of all malaria deaths occur in Nigeria and The Democratic Republic of Congo (DRC).26 Nigeria has the highest burden of out of school children in the world at 10.5 million and DRC has 3.5 million children out of school. Even after household wealth is taken into account, those with more education are far more likely to take preventative measures and malaria incidence drops in particular when girls and women are educated.27 In a study conducted in India, individuals who are literate and had schooling up to lower secondary level were more than twice as likely as illiterate people to know that mosquitoes are the transmitters of malaria and 45% more likely to know that draining stagnant water can prevent malaria.28
Preventable Childhood Deaths Malnutrition Malnutrition is the underlying cause of 45% of child deaths globally.29 Educating future mothers is absolutely critical to eliminating malnutrition. Hunger will not be eliminated without education.30
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Malnourished children have low resilience and are more likely to get and remain sick and have a harder time performing well in school. Poverty is a key contributor to acute and chronic malnutrition – the poorest children are two times more likely to be chronically malnourished than their richest counterparts.31 Educating mothers is critical to improving nutrition and enabling children to realize their full potential. If all women completed primary education, 4% fewer children would be chronically malnourished. Providing secondary education to women further reduces chronic malnutrition by 26%.32 School feeding programs have also been shown to improve nutrition and child survival among school-going children.33
Diarrhoeal disease Diarrhoeal disease is the second leading cause of death in children under five and the leading cause of malnutrition. Diarrhoeal disease is both preventable and treatable. Among all children under age 14, more than 20% of deaths are directly attributable to unsafe water, inadequate sanitation or insufficient hygiene (WASH).34
When children and teachers in day-care centers and primary schools wash their hands properly with soap, diarrhoea cases can be reduced by 30% or more.35 Protecting the health of children by expanding WASH services in schools promotes hygienic practices that reduce rates of illness both at school and home. Poor girls can spend six hours each day collecting water, leaving little time for school. Those girls that do go to school often drop out when they start to menstruate because there is no safe place to keep clean at school.36 Clean and accessible facilities create a healthy learning environment, which encourages students to attend school regularly.37
Non-Communicable Diseases Access to education, poverty and non-communicable diseases (NCDs) are closely linked – nearly 80% of deaths occur in low and middle-income countries.38 NCD inequalities are also often the result of broader social and economic inequalities between rich and poor. Costs for NCD health care can displace household resources that otherwise might be available for education, especially among poor families, deepening poverty.39 The effectiveness of education as a socio-economic equaliser makes it an essential aspect of combatting NCDs. 40
Increasing people’s access to quality education protects them from disease. In a comprehensive review of challenges and approaches to reducing NCDs in sub-Saharan Africa, a World Bank report showed the burden of NCDs could undo the gains made in poverty reduction, education and health since 2000. Increasing investment in high-quality education, health and related infrastructure is a recommended way to reduce incidences of NCDs.41 Public education is a critical element in promoting preventive action, healthy lifestyles, and addressing stigma.42 A study in South Africa shows that schools create a space where children and young people can learn about healthy behaviors.43
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Critics argue that though the report made a clear compelling link between health and economic development, it also ‘helped some countries to justify a costly retreat from rights-based approaches to health and education.’ (The Lancet, 2013 p. 1904) 2 Chile, China, Costa Rica and Cuba 3 Statistics based on 2010 data from: World Bank http://data.worldbank.org/; United Nations http://data.un.org/ and WHO http://bit.ly/1uwogZb 4 The Lancet (2013). Global health 2035: a world converging within a generation (p. 1919) 5 The Lancet (2013). Global health 2035: a world converging within a generation (p. 1901) 6 Ibid., p. 1912 7 Ibid., p. 1901 8 Ibid., p. 1912 9 UNESCO (2010). Education Counts: Towards the Millennium Development Goals (p.17) 10 UNESCO (2014). EFA Global Monitoring Report - Teaching and learning: Achieving quality for all. (p. 15) 11 Ibid. 12 Ibid., p.15 13 United Nations (2010). Millennium Development Goals Report 14 UNICEF (2014). Adolescents and Young People 15 UNESCO (2014). EFA Global Monitoring Report - Teaching and learning: Achieving quality for all (p. 16) 16 Ibid. 17 WHO & UNAIDS (2008). Addressing Gender Inequalities: Addressing Gender Inequalities: Strengthening HIV/AIDS Programming for Women and Girls. 18 World Bank (2009). The Short-Term Impacts of a Schooling Conditional Cash Transfer Program on the Sexual Behavior of Young Women. 19 Stop TB Partnership. Speech by Mr. Andre Roberfroid 20 Geetharamani, S., et al. (2001). Socio-economic impact of parental tuberculosis on children 21 Zhang, et al. (2014). Experiences of the parents caring for their children during a tuberculosis outbreak in high school: a qualitative study 22 Gopichandran, V., Roy, P., & Sitaram, A. (2010). Impact of a Simple Educational Intervention on the Knowledge and Awareness of Tuberculosis among High School children in Vellore, India 23 WHO (2013). Children: reducing mortality 24 Lucas (2010). Malaria eradication and educational attainment: evidence from Paraguay and Sri Lanka 25 UNESCO (2014). EFA Global Monitoring Report- Teaching and learning: Achieving quality for all (p. 165) 26 WHO (2013). World Malaria Report 2013. 27 UNESCO (2014). EFA Global Monitoring Report- Teaching and learning: Achieving quality for all (p. 165) 28 Sharma et al. (2007). Predictors of knowledge about malaria in India 29 Leading cause of under 5 deaths include pneumonia, birth complications, diarrhoea and malaria – all of these causes are attributable to malnutrition (UN-IGME ,2013 Levels and trends in child mortality 2013) 30 UNESCO (2014). EFA Global Monitoring Report- Teaching and learning: Achieving quality for all (p. 167) 31 Save the Children (2012). A Life Free from Hunger: Tackling child malnutrition 32 UNESCO (2014). EFA Global Monitoring Report- Teaching and learning: Achieving quality for all 33 Neervoort. et al. (2012). Effect of a school feeding programme on nutritional status and anaemia in an urban slum: a preliminary evaluation in Kenya 34 UNICEF (2012). Raising Even More Clean Hands: Advancing Health, Learning and Equity through WASH in Schools 35 Ibid., p. 8 36 WaterAid. Women: Safe water and sanitation transform women's lives, enabling them to fulfill their potential 37 UNICEF (2012). Raising Even More Clean Hands: Advancing Health, Learning and Equity through WASH in Schools 38 WHO (2013). Factsheet: Non-communicable diseases 39 WHO. NCDs and Development 40 Imperial University (2013). New strategy needed to fight non-communicable diseases 41 World Bank (2013). The Challenge of Non-communicable Diseases and Road Traffic Injuries in Sub-Saharan Africa: An Overview 42 African Union (2013). Report on Non-Communicable Diseases (NCDs) 43 UNESCO (2014). EFA Global Monitoring Report- Teaching and learning: Achieving quality for all (p. 162)
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