people and planet

3
Tanzania revealed that many doctors had insufficient
medical knowledge and provided low standards of care to
their patients. Poor patients had access to less competent
doctors who exerted even less effort with them than with
other patients (Das et al., 2008). A review of 122 studies on
informal healthcare providers in low and middle income
countries found they accounted for a highly variable
share of health interactions (ranging from 9% to 90%) and
followed poor practices (Sudhinaraset et al., 2013).
But patients with higher education engage differently
with doctors. Owing to their better mastery of health
knowledge and ability to locate medical information,
educated patients often seek to become ‘co-producers’
of their health. They perceive themselves as sharing
decision-making and responsibility, which can lead to
better treatment adherence and reduced costs (Crisp
and Chen, 2014).
As regards accountability, a synthesis of 71 articles on
doctor–patient relationships in low and middle income
countries confirmed that many healthcare providers
did not listen carefully to their patients’ preferences,
facilitate their access to care, offer them detailed
information or treat them with respect. But education
can help facilitate measures to enforce accountability
by, for instance, ‘creating official community
participation mechanisms in the context of health
service decentralization; enhancing the quality of health
information that consumers receive; [and] establishing
community groups that empower consumers to take
action’ (Berlan and Shiffman, 2012, p. 272).
Education levels also matter in adopting healthier and
more environment-friendly energy options. Female
education is strongly associated with choosing modern
energy sources and technology (Ekouevi and Tuntivate,
2011). Meta-analytic reviews confirm that education
levels matter in improving take-up of cleaner cook
stoves and fuels (Lewis and Pattanayak, 2012; Malla and
Timilsina, 2014). In Ethiopia, households with higher
levels of education were more likely to use non-solid
fuels (Mekonnen and Köhlin, 2009). In rural China,
several studies have linked education levels with the
adoption of cleaner fuels, such as biogas. A study
by Zhang and colleagues of nine Chinese provinces
found that the probability of adopting cleaner fuels
increased by 0.66% for every year of education (Shen
et al., 2014). Analysis of the household energy mix in
Uganda indicates that education is critical in increasing
consumption of cleaner fuels (Lee, 2013).
SCHOOLS CAN DELIVER KEY HEALTH
INTERVENTIONS THAT MAY INFLUENCE
OUTCOMES AND BEHAVIOUR
Health and nutrition interventions
As access to education continues to expand, and school
systems reach an unprecedented global share of the
child and adolescent population, the potential for
delivering health and nutrition interventions through the
education sector has never been so great.
School-based interventions, such as meals and health
campaigns, can have an immediate impact on students’
health and nutrition status. School meals provided at the
primary and secondary levels may increase attendance,
alleviate short-term hunger and improve nutrition status,
and are a key multisector intervention (see Chapter 6:
Partnerships). Programmes often target locations with
high poverty or schools with low attendance. Meals
may be served at breakfast or lunch, and be pre-cooked
or cooked in the school. Take-home rations, such as a
monthly portion of cereals and oil, are sometimes made
conditional on attendance. A study in northern rural
Burkina Faso showed that daily school lunches and a
monthly take-home
ration of 10 kilograms
School feeding
of flour (conditional on
girls attending at least
programmes in Burkina
90% of class hours)
Faso increased female increased female
enrolment by 5 to 6 enrolment by 5 to 6
percentage points after
percentage points
one year. Take-home
after one year
rations also improved
the nutritional status
of beneficiaries’
younger siblings (aged 1 to 5) (Kazianga et al., 2012).
A systematic review of 26 studies conducted mostly
in countries of sub-Saharan Africa, South-eastern Asia,
Southern Asia, and Latin America and the Caribbean
found that school meals consistently improved health
and nutrition outcomes, including anaemia, nutrient
levels and morbidity. Some of the programmes also
improved students’ growth, but many did not reduce
the prevalence of stunting or wasting, as meals served
in primary and secondary school are too late to
compensate for these results of chronic early childhood
malnutrition (Lawson, 2012).
In higher income countries, school meal policies are
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CHAPTER 3 | PEOPLE: INCLUSIVE SOCIAL DEVELOPMENT