National School Health and Nutrition Strategy

National School Health and Nutrition Strategy Ministry of Education, October 2012 THE FEDERAL DEMOCRATIC REPUBLIC OF ETHIOPIA NATIONAL SCHOOL HEALTH AND NUTRITION STRATEGY To Be Healthy to Learn and to Learn to be Healthy Ministry of Education Addis Ababa, Ethiopia 1 TABLE OF CONTENTS FOREWORD ....................................................................................................................................3 ACKNOWLEDGEMENTS ...............................................................................................................4 OPERATIONAL DEFINITIONS .......................................................................................................5 ABBREVIATIONS AND ACRONYMS ............................................................................................6 1. INTRODUCTION ......................................................................................................................7 1.1 Background.................................................................................................................. 7 1.2. RATIONALE ................................................................................................................ 8 1.3. GOAL........................................................................................................................... 9 1.4. OBJECTIVES .............................................................................................................. 9 1.5. SCOPE AND APPLICATION ....................................................................................... 9 2. SUPPORTING POLICIES ...................................................................................................... 10 2.1. Education Sector ............................................................................................................10 2.2. HealthSector ...............................................................................................................10 2.3. Agricultural Sector.......................................................................................................11 3. GUIDING PRINCIPLES ......................................................................................................... 11 3.1. Government Leadership .................................................................................................11 3.2. Multi-Sectoral Approach ..............................................................................................11 3.3. Access to Health and Nutrition Services .....................................................................11 3.4. Access to Safe Water, Sanitation and Hygiene ...........................................................11 3.5. Access to Education ...................................................................................................12 3.6. Access to Information .................................................................................................12 3.7. Equality, Equity and Non-Discrimination .....................................................................12 3.8. Privacy and Confidentiality ..........................................................................................12 3.9. Safety in Learning Institutions .....................................................................................12 3.10. Gender Sensitivity .......................................................................................................12 3.11. Partnerships................................................................................................................12 4. SHN STRATEGIC FRAMEWORK ......................................................................................... 13 4.1. Strategic Components ....................................................................................................13 4.1.1. School health- and nutrition-related policies ................................................................. 13 4.1.2. Safe and sanitary school environments ......................................................................... 14 4.1.3. Skills-based health and nutrition education................................................................... 14 2 4.1.4. School-based health and nutrition services .................................................................. 15 4.2 Supportive Strategic Components ........................................................................................... 15 4.2.1. Country-wide SHN capacity building ......................................................................... 15 4.2.2. SHN planning and implementation structure ........................................................... 16 4.3. SHN strategy focus areas and activities ......................................................................16 4.3.1. Inclusion of SHN issues in the curriculum ................................................................ 17 4.3.2. Disease prevention and control .................................................................................. 17 4.3.3. Nutrition, school canteen and food policy ................................................................. 19 4.3.4. Water, Sanitation and Hygiene (WASH) ................................................................... 20 4.3.5. Values and life skills ..................................................................................................... 20 4.3.6. Special needs and disabilities .................................................................................... 20 4.3.7. Child rights and child protection ................................................................................. 21 4.3.8. Schools infrastructure and environmental safety .................................................... 21 4.3.9. Effective community partnerships .............................................................................. 21 4.3.10. Pupil awareness and participation ......................................................................... 22 5. SHN STRATEGIC IMPLEMENTATION ................................................................................ 23 5.1. Establishing an institutional framework ................................................................................. 23 5.2. Collaboration and networking ............................................................................................. 24 5.3. Advocacy and resource mobilization ................................................................................. 24 5.4. Monitoring and evaluation ................................................................................................... 24 6. ROLES AND RESPONSIBILITIES ........................................................................................ 25 6.1. Joint Responsibilities of Government Ministries ..............................................................25 6.1.1. Responsibilities of the Ministry of Education..................................................................... 25 6.1.2. Responsibilities of the Ministry of Health ........................................................................... 26 6.2. Other Stakeholders .....................................................................................................26 6.2.1. Responsibilities of the Community................................................................................. 26 6.2.2. Responsibilities of All Stakeholders............................................................................... 27 6.3. Memorandum of Understanding ..................................................................................27 7. ORGANIZATIONAL STRUCTURE ....................................................................................... 28 7.1. National SHN Inter-Agency Coordinating Committee ......................................................28 7.2. National SHN Taskforce/Technical Committee ...........................................................28 8. REFERENCES ....................................................................................................................... 30 3 FOREWORD In recent years, there has been an increased awareness that poor health and nutrition affect children’s ability to learn. It has also been recognized that health and nutrition problems are associated with school attendance and concentration. Despite these facts, up until recently, the health and nutrition needs of school-age children have been largely ignored. The focus has instead been on pre-school children because they are at greater risk of mortality. However, since more children are now attending school than ever before, the concerns shift away from mere survival towards improving the quality of life. Interventions aimed at schoolchildren are being increasingly viewed as vital to improving the health and nutrition status of the population as a whole. The Ministry of Education is responsible for gearing the younger generation towards better working potential and productivity, equipping students with the necessary knowledge including health and nutrition. To this end, the Ministry has developed a National School Health and Nutrition Strategy. Fuad Ibrahim Omer State Minister for General Education, Ministry of Education, The Federal Democratic Republic of Ethiopia 4 ACKNOWLEDGEMENTS This School Health and Nutrition Strategy was produced following a series of consultations and collaborative efforts of different stakeholders. The Ministry of Education wishes to acknowledge the contributions and commitment of the National School Health and Nutrition Taskforce as well as the support from a number of development partners who contributed to the preparation and production of this National School Health and Nutrition Strategy document. Special thanks go to the National School Health and Nutrition Taskforce with team members comprising of the Ministry of Health, Agriculture, Women, Youth and Children Affairs, Water and Energy, the UN-World Food Programme, Save the Children UK and US, USAID, WHO, UNICEF, World Bank and other partners. In the end, the Ministry of Education would like to extend its utmost thanks to the UN-World Food Programme, Save the Children US and UNICEF for their financial and technical input. 5 OPERATIONAL DEFINITIONS Adolescent Any person between 10 to 24 years of age. Child Any person less than 18 years of age. FRESH A framework that enables to respond to the different health and nutrition conditions of school age children through the integrated application of different components. School-age children Children attending schools at all levels in the country. 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 and nutrition An integrated set of planned school-based strategies, activities and services designed to promote the optimal physical, mental, social, spiritual and educational development of students and to improve the health of the surrounding community. Home Grown School Feeding A school feeding programme that provides food produced and purchased within a country where the programme is implemented. SHN Inter-Agency Coordinating CommitteeAn inter-sectoral SHN committee comprising mainly of the Ministries of Education, Health; Women, Children and Youth Affairs; Water Resources and other relevant stakeholders. Stakeholder An individual or organization that partners and collaborates in School Health and Nutrition interventions. WASH (Water, Sanitation and Hygiene) Interventions aimed at ensuring safe and adequate water supply as well as proper sanitation and hygiene promotion for realizing a healthy and hygienic school environment. 6 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy CSA Central Statistics Agency EFA Education for All EMIS Education Management Information System ESDP Education Sector Development Programme FRESH Focusing Resources on Effective School Health GEQIP General Education Quality Improvement Programme HGSF Home Grown School Feeding HIV Human Immunodeficiency Virus IDD Iodine Deficiency Disorder IEC Information, Education, and Communication MoE Ministry of Education of Ethiopia MoH Ministry of Health NGO Non-Governmental Organization SHN School Health and Nutrition SHN-IC School Health and Nutrition Inter-Agency Coordinating Committee SIP School Improvement Programme STH Soil Transmitted Helmenthes STI Sexually Transmitted Infections TB Tuberculosis UNCRC United Nations Convention on the Rights of the Child WASH Water, Sanitation and Hygiene 7 1. INTRODUCTION 1.1 Background School-age children in Ethiopia are affected by a wide range of health- and nutrition-related problems that constrain their ability to thrive and benefit from education. Some of the common health-related problems being parasitic infections, malaria, anaemia, trachoma, skin diseases, disabilities, injuries, sexual and reproductive ill-health, and psychosocial and substance abuse. Some of the common nutrition-related problems being inadequate food consumption and associated levels of malnutrition as well as iodine and vitamin A deficiency, in most of the Ethiopian regions. Furthermore, there are low awareness levels on the effect of poor health and nutrition on children’s ability to learn. From a policy and strategy perspective, there is lack of ownership and coordination as well as ineffective utilization of resources due to different standards being applied by different organizations on the delivery of comprehensive school health and nutrition (SHN) interventions. In Ethiopia’s efforts to achieve universal access to basic education, many more children now have the opportunity to go to school and hence, more children can be reached by the school system than ever before. From the perspective of the health sector, a SHN strategy would enable the health and nutrition status to be improved for a significant proportion of Ethiopia’s population, promoting healthy attitudes, knowledge and behaviours throughout their lifetime. In light of this; in tackling the above constraints; in being part of Ethiopia’s drive towards Education for All (EFA);and following the 2008 Annual Review Meeting; a National SHN Taskforce/Technical Committee(co-chaired by the Ministries of Education and Health and comprising of other government line ministries, a range of international development partners, and non-governmental organizations [NGOs]) was established and entrusted with developing a National SHN Strategy for the country. The Ministry of Education recognizes the impact that poor health and nutrition can have on children’s ability to learn, on their school attendance and on concentration. They also recognize that diseases, disabilities, and ill-health are major impediments for effective learning, for children’s full productive potential, and for the national development and poverty reduction efforts. With more children attending school than ever before, interventions aimed at schoolchildren are increasingly viewed as vital in improving the health and nutrition status of the population as a whole. It is estimated that there are 33,284 government and non-government schools, 18,850,986 school-age children and some 376,937 teachers in primary and secondary levels of education in the country (MoE-EMIS, 2011). To this end, the Ministry of Education is committed to the promotion of quality health and nutrition for school-age children (including under-fives) and adolescents (10 to 24years old)who constitute 15% and 35% respectively of the total population (CSA, 2008), and of whom a major portion suffer from alarming levels of ill health, nutritional deficiencies and morbidity, and which has called for the development of this National SHN Strategy. This document therefore, presents a national strategy for SHN in Ethiopia. It is based on extensive evidence collected during a nationwide situation analysis on the health, nutrition and 8 education of schoolchildren conducted in 2008 (July to September) through a process of visits to all Ethiopian regions, a literature review, and consultations with multiple stakeholders (MoE, 2008). 1.2. RATIONALE Schoolchildren are often thought of as naturally healthy, but studies have shown that many schoolchildren are stunted in height, underweight, wasted, anaemic, and iodine or vitamin A deficient. In many areas schoolchildren are affected by health- and nutrition-related problems that constrain their ability to thrive and to benefit from education. These highly prevalent health and nutritional conditions, common in a number of Ethiopian regions, are all believed to lead to impaired cognitive ability. The national SHN survey conducted in 2008 (MoE, 2008) showed that 23% of surveyed children were stunted and a similar percentage of them were also underweight. The survey also indicated a prevalence of 12.8% in national night blindness, a prevalence of 13.8% in Iodine Deficiency Disorder (IDD), and an IDD survey conducted in 2005/2006 found that 40% of schoolchildren had goitre (EHNRI, 2006). In Ethiopia, reasons for leaving school among adolescents differ by sex and rural/urban residence. The main reason cited by girls was early marriage (29% for urban) and in particular 40% of rural girls mentioned early marriage as their main reason for leaving school (Ethiopia young adult survey, 2009).However, many of these conditions could readily be addressed by a well-designed and implemented SHN programme which addresses the critical health and nutrition factors that keep children out of school and reduce their ability to learn. Good health and nutrition are essential for learning and cognitive ability. Ensuring good health and nutrition provision when children are of school-age can boost attendance and educational achievement. School-based methods of promoting healthy behaviours are amongst the most successful and cost-effective ways of tackling some major problems of adolescence such as violence, substance abuse, teenage pregnancy, and sexually transmitted diseases, including HIV and AIDS. In the past, school-based health and nutrition programmes were fragmented and uncoordinated due to being implemented by different stakeholders, which led to inefficient and ineffective programme delivery as well as poor results. Most of the efforts were piecemealed and not planned on a sustainable basis. In order to ensure that the capacities of the education, health and water sectors as well as communities and other stakeholders are harnessed, to such an end, a well-designed SHN strategy is crucial. This SHN strategy shall fill the gaps and harmonize and strengthen existing SHN interventions and shall serve as a tool for the integration and reinforcement of broader SHN interventions. A comprehensive SHN programme meets a greater proportion of health, nutrition and psychological needs of school-age children as schools provide an organized structure that is conducive for the promotion and provision of health and nutrition services as well as a key avenue for disease prevention and control such as through de worming campaigns and other immunization services. Schools are ideal settings to implement health and nutrition programmes because they offer substantial opportunities to promote health and nutrition. As well as promoting educational quality, SHN promotes equity, as children who begin school have the 9 most to gain from SHN interventions as they have the worst health and nutrition status. It also enables them to benefit from better educational outcomes, since they show the greatest improvement in cognition from SHN interventions. Thus, SHN particularly benefits the poor and the disadvantaged, many of whom are increasingly accessible through schools as a result of Ethiopia’s universal education strategies. 1.3. GOAL To improve access and educational achievement of schoolchildren through health and nutrition interventions in educational establishments in Ethiopia. 1.4. OBJECTIVES The main objectives are:  To promote joint planning, designing and implementation of sustainable and quality health and nutrition interventions across the education sector.  To strengthen coordination, linkage and partnership of SHN interventions by relevant ministries, communities and other stakeholders. The specific objectives are:  To improve the quality of education by ensuring the development of child-friendly school environments.  To promote the provision of safe and sanitary school environments which includes clean and potable water that is well maintained and with gender-segregated hygiene and sanitation facilities.  To promote the provision of health and nutrition services that can be readily delivered through schools and close to the children’s locality.  To complement policies and strategies which define how health and nutrition is to be addressed in schools.  To promote skills-based health and nutrition education that is delivered by trained teachers and health personnel at all levels.  To ensure mechanisms are put in place for ownership and sustainability of SHN programmes (such as school feeding programmes and other promotive nutrition interventions, cooking demonstrations and school gardens) thereby, increasing access and completion rates by reducing dropout and absenteeism prevalent in chronically food insecure areas of the country. 1.5. SCOPE AND APPLICATION The National SHN Strategy shall be applied to all students, teachers, and other staff in public, private, formal and informal education and training institutions at all levels and sub-sectors of the education system in Ethiopia. 10 2. SUPPORTING POLICIES The proposed National SHN Strategy is supported by a number of existing sector policies from education, health and water in Ethiopia. Principal amongst these are: 2.1. Education Sector Ethiopia’s Education and Training Policy (1993): Has the objective of “developing the physical and mental potential and the problem solving capacity of individuals by expanding education and in particular by providing basic education”. Education Sector Development Programme (ESDP IV): States that ensuring good health and nutrition when children are of school-age can boost attendance and educational achievement and envisage that a SHN strategy can promote learning while simultaneously reducing repetition and absenteeism, and can be among the most cost-effective means of improving educational quality. Education Sector Policy on HIV&AIDS (2008): States that “all education and training institutions and organizations will put in place precautions that protect learners from HIV infection by addressing the health, nutrition, water and sanitation concerns that aggravate the susceptibility and vulnerability of learners to HIV&AIDS”. 2.2. HealthSector Ethiopia’s Health Policy (1993):Supports the participation of the health sector in SHN programmes and makes particular mention of the role of schools in the promotion of information, education and communication (IEC) activities. Health Sector Development Programmes (HSDPs):The successive HSDPs developed over the past two decades have directly or indirectly included a range of activities relevant to SHN. National Nutrition Strategy: Calls for nutrition education to be integrated into the formal curriculum and the promotion of capacity building efforts through pre-service and in-service trainings Safe and Sanitary Environments: Supported by the WASH (Water, Sanitation and Hygiene) in Schools Memorandum of Understanding that lays out the respective sector policies for education, health and water with respect to water and sanitation in schools. Skills-Based Health Education: Supported by the Ministry of Education policy that seeks to develop children’s physical and mental wellbeing and by a number of policies by both Ministries of Education and Health that envisages a specific role for education in improving children’s health and nutrition (such as reproductive health and HIV and AIDS). 11 School-Based Delivery of Health and Nutrition Services: Supported by the Ministry of Education policy that seeks to develop children’s physical and mental wellbeing and by the Ministry of Health policy that supports the sector’s involvement in SHN programmes. Tripartite Agreement among the Ministries of Education, Health and Water Resources: The Memorandum of Understanding among the Ministries of Education, Health and Water Resources, on WASH, commits the three Ministries to work together to improve access to clean potable water and sanitation in Ethiopian schools. 2.3. Agricultural Sector The Federal Democratic Republic of Ethiopia Food Security Strategy (FDRE FSS, issued in 1996) has included some explicit and implicit goals and objectives relevant to SHN. 3. GUIDING PRINCIPLES The guiding principles put below basically emanate from existing international conventions, national laws, policies, guidelines and regulations. They include the following major issues: 3.1. Government Leadership The Ministry of Education is the primary body responsible for providing SHN interventions and thus, shall provide leadership and establish the policy framework for the planning, coordination and implementation of SHN interventions. 3.2. Multi-Sectoral Approach Given the multi-dimensional nature of health and nutrition issues, there shall be a multi-sectoral approach mainly among the Ministries of Education; Health; Agriculture; Water Resources; Women, Children and Youth Affairs; Labour and Social Affairs; and a range of development partners; the private sector; civil society organizations; and the community. 3.3. Access to Health and Nutrition Services Every child has a right to quality health and nutrition services. School establishments are expected to be the tool towards achieving this goal in partnership with the communities. Access to health and nutrition services shall be arranged especially for poor and vulnerable children. 3.4. Access to Safe Water, Sanitation and Hygiene Every child has a right to access to safe drinking water and adequate sanitation. Provision of safe water and sanitation shall be complemented by appropriate hygiene promotion and education. 12 3.5. Access to Education Every child has a right to quality education. Access to education will continue to be facilitated for vulnerable groups (i.e. girls, orphans, children with disabilities and special needs). 3.6. Access to Information Every child shall have access to relevant health- and nutrition-related information, knowledge and skills that are appropriate for their age, gender, culture, language and context including children caught up in emergencies. 3.7. Equality, Equity and Non-Discrimination Learning institutions shall adopt SHN programmes to respond to the specific needs of girls, children with disabilities, orphans and other vulnerable children. Every child shall have equal rights, opportunities and responsibilities as any other child and shall be protected from all forms of discrimination. 3.8. Privacy and Confidentiality Every child has the right to privacy and confidentiality regarding their health. A child’s health status and medical condition shall not be disclosed to other children without the consent of the child (or the consent of the child’s legal guardian acting in the best interest of the child). A child’s medical information may be accessed by authorized health personnel, parents and teachers in order to provide medical advice, treatment or to prevent the spread of infectious diseases. 3.9. Safety in Learning Institutions All learning institutions shall provide safe and accessible physical environments. They shall be responsible for minimizing the risk of physical injury and disease transmission by ensuring that adequate safety measures are put in place. In addition, all learning institutions shall provide safe psychosocial environments. There shall be no tolerance of sexual harassment, abuse and other forms of exploitation. 3.10. Gender Sensitivity Planning and implementation of SHN programmes shall be sensitive to the different needs of boys and girls. 3.11. Partnerships Effective partnerships shall be developed at all stages of planning and implementation of SHN programmes as well as joint fundraising and advocacy strategies. 13 4. SHN STRATEGIC FRAMEWORK This National SHN Strategy will adopt the FRESH (Focusing Resources on Effective School Health) framework as its guiding conceptual framework which aims at enabling effective coordination and organization of SHN responses in the country. As part of the main strategic component, four priority areas are focused on (as identified in the FRESH framework): school health- and nutrition-related policies; safe and sanitary school environments; skills-based health and nutrition education; and school-based health and nutrition services. As part of its supportive strategic components two areas are focused on: country-wide SHN capacity building; and a SHN planning and implementation structure. The National SHN Strategy also consists of particular SHN focus areas and activities, all of which are detailed below. The Ministry of Education in collaboration with relevant sector ministries will ensure that the school curricula addresses relevant health and nutrition challenges in the country. The curricula will cover areas which include knowledge, values, attitudes and life skills needed to ensure the quality of life of schoolchildren. The curriculum shall provide basic information about health and nutrition issues to students and shall develop skills-based learning experiences to influence the development of desirable health and nutrition habits and discourage unhealthy practices. The National SHN Strategy shall also support and augment other activities occurring in Ethiopia that aim to improve educational quality such as the General Education Quality Improvement Programme (GEQIP) and School Improvement Programmes (SIPs). The National SHN Strategy aims to help ensure that children are healthy and better nourished and able to take full advantage of what is often their only opportunity for a better life through better education. By doing this, SHN promotes learning, and simultaneously reduces repetition and absenteeism, in a cost-effective way there by, improving educational quality. In order to achieve the goal identified, the National SHN Strategy necessitates establishment of an institutional framework for coordination and resourcing of SHN at all administrative levels in Ethiopia, integrating SHN in ESDPs, GEQIP and SIP, country-wide SHN capacity building, planning and implementation mechanisms as well as strong monitoring and evaluation systems. 4.1. Strategic Components The National SHN Strategy for Ethiopia will concentrate on a certain set of strategic components (main and supportive) as well as focus areas and activities that will be helpful in addressing the health- and nutrition-related challenges of school-age children. The SHN strategic framework provides both short-and long-term solutions to SHN problems, equips stakeholders and communities with skills and infrastructure to address health and nutrition problems that affect children, and in general enables them to bring about the desired result. The SHN main strategic components are: 4.1.1. School health- and nutrition-related policies The Ministry of Education in collaboration with the Ministry of Health and other pertinent stakeholders shall develop health and nutrition strategies and guidelines for schools to enable them to promote the overall health, hygiene and nutrition of children/students. Furthermore, 14 strategies shall be put in place to ensure a safe and secure physical environment and a positive psychosocial environment, and to address issues such as abuse, sexual harassment, school violence, and bullying. Strategies regarding the health-related practices of teachers and students can reinforce health education: teachers can act as positive role models for their students. Health policies and strategies in schools, mandating a healthy, safe and secure school environment, guaranteeing equal rights and opportunities and regulating the provision of health education and health services, are the blueprints for action necessary to harness the potential of health in improving education outcomes. 4.1.2. Safe and sanitary school environments The Ministries of Health, Education and Water Resources shall provide standard guidelines for ensuring that school premises are clean, structurally safe and functional for all including those with disabilities and special needs. Hence, all educational and training institutions and organizations shall ensure compliance with the building standards, public health rules and other relevant legislations and policies. By providing clean and potable water and sanitation facilities, schools shall reinforce the health and hygiene messages, and serve as demonstration places to both students and the wider community. Separate latrines for girls and boys should be arranged, particularly for adolescent girls. Sound maintenance policies shall help ensure the continuing and safe use of these facilities. Safe water and appropriate sanitation facilities are basic first steps towards a healthy, safe and secure learning environment for boys and girls. 4.1.3. Skills-based health and nutrition education Literacy and numeracy education may amount to nothing if essential life skills are not also developed. Skills-based health education goes beyond the provision of factual information to promote attitudes, values and skills associated with physical and mental health. This approach to health, hygiene and nutrition education focuses upon the development of knowledge, attitudes, values, and life skills needed to make and act on the most appropriate and positive health-related decisions with respect to issues such as HIV and AIDS, early pregnancy, appropriate nutrition throughout the lifecycle, injuries, violence, and tobacco and substance use. Health in this context extends beyond physical health to include psychosocial and environmental health issues. The development of attitudes related to gender equity and respect between girls and boys, and the development of specific skills, such as dealing with peer pressure, are central to effective skills-based health education and positive psychosocial environments. It is also expected that such skills-based health and nutrition education will have spill-over effects on the children’s families and the surrounding communities with regards to knowledge, attitudes and practices in health and nutrition. To ensure that skills-based health and nutrition education is provided in schools, the following shall be accomplished:  Skills-based health and nutrition education materials included in new textbooks and supplementary readings shall be produced to accompany the new curriculum.  A team of experts and trainers in skills-based health and nutrition shall be trained and deployed at federal and regional levels. Such trainers would be drawn from the teacher training colleges and from federal and regional Ministries of Education and Health staff. 15 These experts and trainers shall work with the Federal Teacher Development Department to agree on the positioning, design, content and methodology of skills-based health and nutrition education within the pre-service curriculum of teacher training colleges and within in-service training activities.  The team of experts and trainers shall train members of regional teacher training colleges, teachers and relevant staff of schools to deliver skills-based health and nutrition education teacher training.  Teacher training colleges shall teach skills-based health and nutrition education during pre-service and in-service training of teachers. 4.1.4. School-based health and nutrition services Poor health and malnutrition result in the loss of a considerable number of school days annually. To protect their investment in efforts to increase access and improve the quality of education, schools must help link students to essential health and nutrition services. Schools can effectively deliver health and nutritional services provided that these are simple, safe and familiar, and address problems that are prevalent and recognized as important within the community. Linkages shall be promoted among regular health and nutrition services with school activities including regular monitoring of nutritional status of school-age children/students. In many countries, under the supervision of local health workers, appropriately trained teachers deliver some services directly, for example by providing children with frequent (6-monthly or annually) oral treatment for micronutrient deficiencies and worm infections. With respect to nutrition, school feeding programmes and other nutritional interventions such as weekly iron supplementation, are other services that schools shall provide with the support of local communities. 4.2 Supportive Strategic Components The SHN supportive strategic components are: 4.2.1. Country-wide SHN capacity building Considering the paradigm shift from the purely medical approach to the FRESH inspired approach to SHN, the education sector acknowledges the contribution that comprehensive SHN can make to educational quality. The health sector also understands the impact that SHN can have on the nation’s health and nutrition since almost all children in Ethiopia now attend school. In order to consolidate and extend this new understanding, the strategy proposes that extensive capacity building of staff charged with the coordination and implementation of SHN be made at all administrative levels. It is proposed that an extensive programme of capacity building will be necessary if the “paradigm shift” in understanding SHN, required for the effective implementation of activities at all levels, is to occur. The aim of capacity building would be:  To equip relevant staff with the required skills and knowledge of SHN that would enable them to plan and implement activities.  To motivate coordination staff and to enable them effectively to sensitize other stakeholders at their level about SHN. 16  To enable coordination staff to act as trainers of those in the administrative level under them (a cascade model of capacity building is envisaged moving from federal and regional levels through to Woreda, Kebele and school levels).  To enable coordination at each administrative level to collect data that will enable activities to be monitored, evaluated and strengthened. Overall, systematic capacity building programmes will be designed and implemented that should be need-based and targeted which will be led by the Ministries of Education and Health and other stakeholders as found appropriate and applicable. Relevant personnel at all levels will be trained on an on-going basis (i.e. pre-service, in-service and on the job-training). 4.2.2. SHN planning and implementation structure In order to enable schools and communities to have ownership of the SHN programmes and to ensure long-term sustainability, the strategy shall follow a “bottom-up” approach in the design and implementation of SHN programmes. At the same time, given that comprehensive SHN is a relatively “new” concept in Ethiopia, there shall also be a system to ensure that schools and communities are able to access good technical advice that would enable them to make good decisions. It is considered that the provision of such good technical advice comes through a “top down” approach through cascading capacity building programmes to different levels included in the strategy’s provision for capacity building. It is proposed that the “bottom up” and “top down” approaches shall be met as follows:  School SHN teams would identify SHN-related problems with members of their local community and prioritize activities to be included in the schools SHN plan.  Woreda SHN teams would be responsible for compiling a “menu” of health and nutrition conditions in their locality amenable to being addressed through SHN interventions.  Woreda teams would be responsible for identifying local resources to support SHN interventions in schools. Such resources shall come from government budgets, development partners and other stakeholders.  The SHN plan would be included in the school’s annual plan and submitted to Woreda for approval and resourcing in line with standard procedures.  Woreda shall return the plan to the school, indicating its approval/amendments and also resources available to the school to implement the plan (resources shall come from the SIP, the School Grants Programme or from other sources such as NGOs and other development partners).  Schools would then approach their communities in order to identify any additional resources needed for the plan’s execution.  SHN interventions (development of school health- and nutrition-related policies, development of safe and sanitary school environments, delivery of skills-based health and nutrition education, and delivery of school-based health and nutrition services) would then be implemented by the school and its local community. 4.3. SHN strategy focus areas and activities The National SHN Strategy will have the following major focus areas and activities: 17 4.3.1. Inclusion of SHN issues in the curriculum The Ministry of Education in collaboration with the Ministry of Health and relevant stakeholders shall ensure that health and nutrition issues be included in the school curriculum and be taught as subjects in all schools. In addition to this, the ministry shall also facilitate and support provision of health services in schools such as counselling and social services, visits by nurse/doctor, referral systems, immunization and dental services. 4.3.2. Disease prevention and control Diseases negatively affect learning and may result in repeated absenteeism and even complete dropout of school. In light of these, schools shall ensure that they put in place measures aimed at preventing diseases through health education and implementation of preventive and control interventions. 4.3.2.1. School Eye Health Health, including visual health, is inextricably linked to school achievement, quality of life, employability and economic productivity. Health education in the school setting is of fundamental importance for building knowledge of child and adolescent health and developing the values, habits, abilities, skills and practices necessary for a healthy life. This policy provides the basic directions to develop appropriate eye health components within a school health programme based on a coordinated approach between the education and health ministries and parents/carers. The component on vision screening linked to accessible and affordable refraction and corrective services will address uncorrected refractive errors and irreversible low vision. The school eye health programme area will be backed by eye and child health services to manage referrals and encompass the following:  Eye health promotion; i.e. health education and literacy, empowerment, increasing awareness  Identification of children with visual impairment;  Correction of refractive error, provision of high quality spectacles which look good (to help take-up and usage) and which are comfortable, durable and affordable;  Primary management for common and acute cases, eg infections, trauma,  Programmes for locally endemic diseases especially those targeted for elimination eg trachoma, and conditions of public health significance eg Vitamin A deficiency  Identification, referral and treatment of potentially visual impairing conditions e.g. cataract;  Healthy practices eg personal hygiene -face washing, hand washing for trachoma control;  Promoting a healthy school environment e.g. growing vitamin A rich foods in a school garden; water collection for face washing; clean latrines and waste management and flies control 18  Using the Child-to-Child approach to take eye health messages home, and to use children as “case detectors” of individuals in their families or community who need eye services.  Screening of siblings of children with refractive errors and other familial conditions  How to help and interact with other children and adults who are irreversibly low vision or blind  Training of Teachers for screening and correction of presbyopia 4.3.2.2. Tuberculosis Tuberculosis (TB) is transmitted through the air which means that school children can be at higher risk of getting infected within the school. Teachers have the potential in identifying children that have symptoms of and could refer them to the nearest health facility for further check-up. In this regard, the following shall be implemented in schools:  Classrooms shall be spacious with adequate ventilation to prevent TB transmission  Teachers shall identify students with chronic cough lasting for two or more weeks and refer them to health facilities  Children and the entire school community shall be taught on coughing hygiene and encouraged not to spit anywhere in the compound  Children, school staff and the surrounding community members shall be sensitized on TB treatment and encouraged to ensure that the sick complete their medication 4.3.2.3. HIV / AIDS and sexually transmitted Infections (STIs) All schools and learning institutions have a responsibility of addressing HIV, AIDS and STIs through education by developing skills and values and attitude changes to promote positive behaviours.  All existing policies on HIV / AIDS and STI control shall be adhered to  There shall be no discrimination of HIV positive students, teachers, and staff  Those affected by HIV / AIDS and STI shall be allowed and encouraged to access treatment including Antiretroviral Therapy (ART) and regular check-ups  Efforts shall be made to strengthen Anti AIDS clubs in schools in order to prevent spread of the disease 4.3.2.4. Control of Intestinal Worms, Bilharzia, and other Parasitic diseases Children are particularly susceptible to different diseases such as intestinal worms and bilharzia from contaminated soil and water which result in chronic and long-lasting health problems. Chronic worm infestations often make children malnourished, anaemic and vulnerable to illnesses thereby, contributing to decreased cognitive development, low concentration, low intellectual and physical performance and school absenteeism. On the other hand, schools provide a favourable environment for the control of diseases since school children could serve as effective agents in passing messages on prevention and control of diseases and are convenient for mass treatment along with promotion of health messages. As a result:  Schools shall be equipped with improved water, environmental sanitation and hygiene facilities  Children shall be taught good personal hygiene such as regularly washing hands before eating and after visiting the toilet  De-worming serves a preventive and treatment measure which will result in immediate improvement in child health and development and in preventing irreversible 19 consequences in adulthood. Schools shall administer mass de-worming campaigns based on the prevalence and intensity of worms and should include all school-age and out of school children  Schools shall be made to participate in national programmes aimed at addressing neglected diseases and diseases targeted for elimination such as guinea worms  Children and their families shall be taught the benefits of wearing shoes for preventing soil transmitted helminthic (STH), hookworms and other parasites that penetrate the skin 4.3.3. Nutrition, school canteen and food policy This includes school feeding policy and selling policy of food and other products in or around schools, and introducing school gardens. Nutrition as a science teaches the role that food and nutrients play in the human body during growth, development and maintenance of life. Good nutrition is essential to fully realize the learning potential of children and to maximize returns on educational investments. Malnutrition affects a child’s attentiveness, concentration, aptitude and overall performance and has a negative impact on school attendance and enrolment. Due to this, schools shall promote good nutrition practices by integrating nutrition interventions including school feeding programmes and micronutrient supplementation into school activities thereby, reaching a high proportion of children and youth. The curricula shall be regularly reviewed and updated to enhance nutrition information provision and teachers should also be well trained, on an on-going basis, on nutrition issues. School feeding programmes contribute to the alleviation of short-term hunger and helps children concentrate on their studies and enable them to gain increased cognition and better educational outcomes. They also address micronutrient deficiencies such as vitamin A, iodine, and iron among others which directly or indirectly affect cognition and can result in better school performance. Hence, school feeding programmes shall be promoted with the intention of providing balanced meals for children in schools especially for those coming from poor and food insecure households and areas, as well as those affected by natural and man-made emergency situations. Children from well-off families shall also be encouraged and taught to carry nutritious lunch boxes. Communities shall also be involved in planning, resource mobilization and management of school feeding programmes. The Ministries of Education, Health and Agriculture and other relevant ministries and development partners shall work closely with communities and assist and encourage them to ensure a minimum level of local food production to implement a Home Grown School Feeding (HGSF) programme and to ensure sustainability and ownership of the programme. Overall, the following shall be implemented in order to optimize school nutrition services:  Linkages shall be created and promoted between regular health and nutrition services and school activities, including regular monitoring of the nutritional status of children.  Referral services shall be arranged for malnourished children to health facilities, feeding programmes and other services that can respond to identified needs.  Schools shall have gardens for demonstration purposes and to serve as resource centres for learning more about nutrition practically. 20  Standards and regulations shall be developed by the relevant ministries for controlling food handlers and school feeding programmes that cover storage, preparation, and quality of food served to students; those dealing with food handling in and around schools shall be properly trained in hygienic food preparation and serving of quality balanced meals. 4.3.4. Water, Sanitation and Hygiene (WASH) A safe and adequate water supply as well as proper sanitation and hygiene promotion is a prerequisite for realizing a healthy and hygienic school environment. The health benefits that could be derived out of safe and adequate water and in improved sanitation and hygiene are numerous, ranging from a reduction in acute watery diarrhoea, intestinal worms, trachoma, and increased levels of self-esteem from a clean toilet/latrine. The following provisions shall therefore be made:  The school management in collaboration with the communities should be encouraged and assisted to provide adequate, safe and potable drinking water and hand washing facilities to be constructed in each school.  Separate latrines to be constructed for boys and girls and in a way that meets the special needs of children and all age groups.  Standards for toilets/latrines and all other sanitation facilities shall be regularly checked and monitored and their status’ should updated; they should also be checked whether they are relevant to the different geographic locations in the country and that they are sensitive to users of all age groups.  Hygiene promotion is to be child/student centred and an on-going process where the spill over effect from schools to surrounding communities shall positively influence and bring about behavioural change. 4.3.5. Values and life skills Values are beliefs, principles and ideas that help define who people are and the things that guide their behaviour and the way they do things. People obtain values from family, friends, traditional cultures, school environments, religious teachings and life experiences. Children shall be taught and assisted to acquire positive values. On the other hand, life skills are abilities and strategies for adaptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday life. Similarly, children shall also be taught and provided guidance on how they can acquire life skills. 4.3.6. Special needs and disabilities Children with disabilities and other special needs have a right to education. Disability and special needs are major impediments for effective learning, social inclusion and integration. In order to address the challenges of children with disabilities and special needs, the following shall be done: 21  Systems shall be put in place to provide a conducive, fully accessible and inclusive environment for all children and there shall be no discrimination on children with special needs.  Appropriate mechanisms shall be put in place for ensuring the safety and security of physically and mentally ill children.  Teachers shall receive adequate training and acquire skills in order to give comprehensive care and support to children with special needs. 4.3.7. Child rights and child protection Children are the most vulnerable segments of the population due to their age and stage of growth and hence, their rights shall be safeguarded and protected. The United Nations Convention on the Rights of the Child (UNCRC, 1986) and the African Charter on the Rights and Welfare of the child identify four basic child rights namely: survival rights; development rights; protection rights; and participation rights. In light of these rights, the following shall be done:  Systems shall be put in place to provide preventive and curative medical care for vulnerable children.  Feeding programmes shall be established and food supplements be given to vulnerable children especially to those living in poverty and in marginalized areas. 4.3.8. Schools infrastructure and environmental safety Schoolchildren are prone to injuries, accidents and a variety of sudden illnesses that require immediate action to sustain health and prevent complications. Poor infrastructure can aggravate accidents and injuries, can spread diseases, and can result in difficulties in provision of quality education. For these reasons:  The Ministry of Construction and Ministry of Health shall provide guidelines for physical structures in schools and ensure compliance with building codes and other relevant legislations and policies.  School premises shall be clean, structurally safe and functional for all including for those with disabilities and special needs.  The school community shall be oriented on road and fire safety regulations.  Every school shall have a basic first aid kit and other facilities for providing emergency care. 4.3.9. Effective community partnerships Promoting a positive interaction between the school and the community is fundamental to the success and sustainability of any school improvement process. Community partnerships engender a sense of collaboration, commitment and communal ownership. Such partnerships also build public awareness and strengthen demand. Within the SHN component, improvement 22 processes, parental support and cooperation allows education about health to be shared and reinforced at home. The involvement of the broader community (i.e. the private sector, community organizations and women’s groups) can enhance and reinforce SHN promotion and resources. These partnerships, which should work together to make schools more child-friendly, can jointly identify health issues that need to be addressed through the school and then help design and manage activities to address such issues. 4.3.10. Pupil awareness and participation Children shall be active participants in all aspects of SHN, and not simply the beneficiaries. Children while participating in SHN activities will simultaneously learn about health and nutrition by doing. This is an effective way to help young people acquire the knowledge, attitudes, values and skills needed to adopt healthy lifestyles and to support health and education to all. 23 5. SHN STRATEGIC IMPLEMENTATION Central to the National SHN Strategy is the understanding that the impact of different SHN interventions is maximized when they are delivered in an integrated fashion. For example, the impact of provision of sanitation facilities is increased when accompanied by skills-based hygiene education about their proper use. To this end, this National SHN Strategy seeks constantly to identify how different interventions can occur in a coordinated manner in Ethiopia, and for ways in which opportunities for coordination and cooperation can be realized. The SHN programme is an inter-sectoral initiative and its successful implementation demands effective partnership between the Ministries of Education, Health, Water Resources and Agriculture and between their staff including teachers, health workers, water and agricultural extension workers all of which shall collaborate in planning, implementation, monitoring and evaluation of activities. The health sector retains the responsibility for the health of children, but the education sector is responsible for implementing, and often funding for SHN activities. Water and agricultural sectors have important inputs to make as well. These sectors need to identify responsibilities and present a coordinated action to improve health and learning outcomes from children. This can be achieved through, establishing an institutional framework, collaboration and networking, advocacy and resource mobilization, and monitoring and evaluation. 5.1. Establishing an institutional framework Given that SHN is dependent on the concerted action of a number of sectors (including education, health, water, agriculture, and women’s affairs) and other stakeholders, an institutional framework shall be established at all administrative levels to enable coordination of SHN at federal, regional, Woreda, Kebele and school levels. The establishment of the institutional framework will result in the establishment of coordination which will bring together:  Members of government sectors (education, health, water, agriculture, and women’s affairs) and other stakeholders.  Development partners and humanitarian agencies.  Communities (including members of NGOs, and community-based/faith-based organizations).  Parents, teachers and students. The education sector will take the lead on planning, coordination and implementation of SHN activities supported by other sectors and stakeholders and the established coordination will:  Ensure SHN coordination between different sectors and stakeholders at each level.  Enable effective coordination between different administrative levels.  Enable resource identification and allocation at the different levels. At each level, the following coordination structure will be established: (1) A Steering Committee comprising of key decision makers from the Ministries of Education; Health; Water Resources; Women, Children and Youth Affairs; and relevant 24 stakeholders. For example, at regional level, the Steering Committee will comprise of the heads of Bureaus of education, health, water, and agriculture etc. (2) A Technical Committee charged with the day to day coordination of SHN activities. Rather than creating any new structures to undertake this work, it is proposed that at each administrative level, existing structures should be identified that could take on this task. 5.2. Collaboration and networking To implement and sustain comprehensive SHN programmes, there is a need to partner and network with other stakeholders, including civil society, development partners, and the private sector which will be instrumental in contributing technical, financial, material and other resources. 5.3. Advocacy and resource mobilization The National SHN Inter-Agency Coordinating Committee (SHN-IC) shall be responsible for:  Advocacy for allocation of budget for SHN programmes.  Resource mobilization and allocation.  The other respective committees and taskforces shall also mobilize local resources for the planning and implementation of their own programmes. 5.4. Monitoring and evaluation A monitoring and evaluation system shall be developed, specifying mechanisms, tools and indicators helpful for monitoring the effectiveness of SHN programmes in achieving health and educational outcomes. For this, a database shall be created to keep accurate and relevant information by enabling “upward” collation of data from Woreda, regional and federal levels so that progress and changes are tracked and impact measured. The system shall use a simple monitoring and evaluation approach with the primary aim to enable planners at each level to collect data that shall assist them in the on-going planning and implementation of SHN activities. Such data collected “upwards” shall be shared “downwards” through regular communication about the progress of SHN activities at national, regional and Woreda levels. Furthermore, the SHN monitoring and evaluation system shall work towards incorporating the SHN-related data into the existing Education Management Information System (EMIS) which shall be instrumental in providing the required SHN-related information. Monitoring and evaluation shall occur as follows:  Schools shall be equipped with a simple “baseline” data collection tool that shall provide a “starting point” against which to track the progress of their SHN activities.  Schools shall be equipped with a simple monitoring tool to record their SHN progress, strengthening their ability to plan and implement further SHN activities.  Data collected using the monitoring tool shall be used to report to Woreda on their SHN progress using existing reporting mechanisms. 25  School data shall be collated by Woreda, enabling Woreda to monitor its SHN progress and strengthening its ability to plan and implement further SHN activities.  In turn, such data shall be sent to the regional and federal levels, for these levels to monitor their SHN progress and strengthening their ability to plan and implement further SHN activities.  At each monitoring stage, data is reported back to those who have collected it to inform them of the progress of SHN at Woreda, regional and federal levels.  In 3 years and 5 years after the onset of activities, the use of the “baseline” data collection tool is repeated, allowing the evaluation of activities to occur. 6. ROLES AND RESPONSIBILITIES 6.1. Joint Responsibilities of Government Ministries The Ministries of Health and Education shall jointly be responsible for all aspects of school health with regards to:  Development and review of the National SHN Strategy and guidelines for implementation.  Coordination of all SHN stakeholders, bilateral and multilateral partners at national level.  Implementation of all aspects of the National SHN Strategy in schools; planning and implementation of SHN programmes; supervision; and monitoring and evaluation.  Resource mobilization and utilization.  Conducting school-based health and nutrition research, baseline surveys, dissemination of reports and SHN information to relevant stakeholders and the public (including parents and the community).  Design and put in place systems of linking the community to the schools and the health services. 6.1.1. Responsibilities of the Ministry of Education The Ministry of Education shall be responsible for the following aspects of the National SHN Strategy and SHN programmes:  Chairing (co-chairing) the National SHN-IC.  Coordinating all aspects for the implementation of SHN programmes in schools.  Ensuring the revision of teacher training and the school curricula in order to include all aspects of SHN education.  Designing and implementing in-service and other short-term training programmes in the area of SHN using the revised curricula.  Advising and providing direction regarding changes in education policies as they affect SHN programmes.  Establishing and promoting health and nutrition clubs in schools. 26  Involving learners, communities and stakeholders in campaigns to promote health and nutrition in schools.  Provision of adequate and accessible infrastructure and facilities conforming to the required and acceptable health standards. 6.1.2. Responsibilities of the Ministry of Health The Ministry of Health shall be responsible for the following aspects of the National SHN Strategy and SHN programmes:  Co-chairing the National SHN Coordination Committee.  Designing, producing and disseminating IEC materials pertaining to SHN.  Conducting on-going health quality control and all treatment aspects of school health services.  Providing logistics management (i.e. selection, quantification, procurement, storage, distribution, and quality control of medications, vaccines, micronutrients, and other medical materials).  Provision of technical advice and the enforcement of required health and nutrition standards including infrastructure and facilities, and water and sanitation facilities in schools.  Providing advice and training on existing and new health and nutrition policies.  Providing technical support in the training and in-servicing of school personnel.  Provision of technical support on the implementation of core health and nutrition activities.  Ensuring that all relevant Health Acts, Rules and Regulations are enforced.  Ensuring constant availability of essential drugs in the existing health facilities.  Provision of rehabilitative health services.  Complementing the SHN with the Health Extension Programme. 6.2. Other Stakeholders 6.2.1. Responsibilities of the Community The communities around the schools shall be responsible for the following aspects of the National SHN Strategy and SHN programmes:  Active participation in the management of schools.  Resource mobilization and contribution.  Maintenance of appropriate safe and healthy environments around their schools and their homes. 27 6.2.2. Responsibilities of All Stakeholders To ensure successful implementation of the SHN programmes, all stakeholders shall be expected to carry out the following activities jointly as well as individually:  Advocacy.  Capacity building and strengthening of SHN systems.  Complementing government efforts in mobilizing resources as well as in programme implementation.  Dissemination of information on SHN matters. 6.3. Memorandum of Understanding A memorandum of understanding shall be signed among the Ministries of Education, Health and Water Resources. An operational guideline shall be developed to promote coordination and harmonization for implementing the SHN programmes with a view to creating a conducive environment for SHN. 28 7. ORGANIZATIONAL STRUCTURE It is envisaged that the National SHN Strategy and SHN programme implementation structure shall be as follows: Figure 1: Organizational structure for effective SHN programme implementation. 7.1. National SHN Inter-Agency Coordinating Committee The National SHN Inter-Agency Coordinating Committee (SHN-IC)shall be an inter-sectoral committee comprising mainly of the key government line ministries, but not limited to the Ministries of Education, Health, Women, Children and Youth Affairs, Water and Energy Resources and other relevant ministries and stakeholders. The Ministry of Education shall serve as a permanent secretary to the Coordinating Body responsible for coordination, resource mobilization and advocacy. 7.2. National SHN Taskforce/Technical Committee This shall also be an inter-sectoral committee comprising of technical experts from the government line Ministries of Education; Health; Women, Children and Youth Affairs; Water Resources; and other relevant ministries as well as other stakeholders. The National SHN Ministry of Education Ministry of Health National SHN Coordinating Committee National SHN Inter-agency Taskforce/Technical Committee Regional SHN Coordinating Body and Taskforce Woreda SHN Coordinating Body and Taskforce Community/School Level Health and Nutrition Taskforce School Management Committee Community Level Health Facility Committee 29 Taskforce/Technical Committee shall be responsible for monitoring health and nutrition trends, related legislation changes, health and nutrition programmes, and providing technical advice to the SHN-IC. This Committee shall be chaired by the Ministry of Health. Regional, Woreda and community levels SHN Task forces/Technical Committees shall follow the same multi-sectoral approach as applicable in their respective areas. Especially at school level, the Health Extension Workers are expected to create a link between the health facilities and schools, while the School Management Committees and Parent Teacher Associations, and other pertinent stakeholders are expected to contribute their part in developing their areas’ SHN programmes, based on their priorities and identified problems. 30 8. REFERENCES  Education Statistics Annual Abstract 2010/2011, Ministry of Education, Education Management Information System (EMIS), September 2011, Addis Ababa, Ethiopia  Ethiopia’s Education and Training Policy: Ministry of Education (MoE), 1993, Addis Ababa, Ethiopia  Ethiopia’s Health Policy, Ministry of Health (MoH), 1993, Addis Ababa, Ethiopia  Situation Analysis on School Health and Nutrition in Ethiopia, Ministry of Education (MoE), September 2008, Addis Ababa, Ethiopia  Summary and statistical report of the 2007 population and housing census, Central Statistics Agency (CSA), 2008, Addis Ababa, Ethiopia  The Education Sector Policy and Strategy on HIV&AIDS, Responding to the challenges of HIV / AIDS in Ethiopia, The Federal Ministry of Education, October 2009, Addis Ababa, Ethiopia  The Federal Democratic Republic of Ethiopia, Education Sector Development Programme IV (ESDP IV) 2010/11-2014/15 Program Action Plan: Federal Ministry of Education (MoE), August 2010, Addis Ababa, Ethiopia  Ethiopian Health and Nutrition Research Institute (EHNRI, 2006), Addis Ababa, Ethiopia.  Ethiopia young adult survey, 2009  United Nations Convention on the Rights of the Child, UNCRC, 1986