What is the problem?
Parasitic worms infect more than one-third of the world’s population and over 600 million school-age children are at risk of infection with 400 million remaining untreated. School-age children suffer the highest intensity of worm infection and greatest morbidity. The harmful impact on children affects their entire lives:
- Health: worms interfere with nutrient uptake, leading to anaemia, malnourishment and impaired mental and physical development.
- Education: infected children are often too tired or sick to attend school. Worm infections are estimated to cause a loss of 200-524 million years of schooling each year
- Livelihoods: worms pose a severe threat to adult outcomes and economic development. Chronic hookworm infection was suggested to reduce adult wages by up to 43%
The Technical Solution:
Deworming pills are low-cost, easy to administer and effective.
How do we test the impact?
From 1998-2001, J-PAL affiliated researchers Edward Miguel and Michael Kremer conducted a randomised controlled trial of a school-based deworming program in western Kenya. Seventy-five primary schools were randomly assigned to treatment groups and phased into the program over the study duration. The randomised assignment ensured that schools in each group were not systematically different before the intervention, allowing researchers to obtain unbiased estimates of the programme’s impact, even many years after the initial evaluation.
As a part of the school-based deworming program, students were given deworming pills twice yearly and worm prevention education through existing infrastructure. At the end of each program year, student outcomes were compared for schools that received treatment and schools which served as comparison.
Because the program was randomly assigend by school, not by child, the researchers were able to measure the full impact of mass deworming, including the benefits of reduced transmission experienced by neighboring children (“spillover effects”).
Positive outcomes of deworming:
- School Attendance increased for treated and untreated children. Deworming increased school participation by 7.5 percentage points, which equates to a one-quarter reduction in school absenteeism. When students were treated directly through schools, they attended school nearly 15 more days per year.
- Treatment Spilllover: The entire school community benefited from “spillovers” of the deworming treatment. Spillover effects occur because medical treatment reduces the transmission of infections to children. Reductions in infection in non-treated children in the treated schools resulted in an additional 7.3 days of schooling per year and children in nearby comparison schools showed an improved attendance of 6 days.
- Long-term health and productivity increased among dewormed students with an increase in proportion reporting very good health, hours worked in the last week and wages of those out of school.
- Cognition and health improved for young children as these children benefited from spillover effects from dewormed neighbours and siblings.
In response to this evidence, the Task Force at the World Economic Forum launched Deworm the World (DtW). DtW advocates for school-based deworming treatment with policymakers and development partners, and provides technical assistance to governments to support the development and launch of sustainable, large-scale, school-based deworming programmes. To date, J-PAL’s evidence has contributed to the deworming of 100 millon children worldwide through newly formed school-based deworming programs.
Policy Lesson 1: Deworming is a “best buy” for health, education and development. Deworming would be a worthwhile investment on the strength of these short-term benefits alone, but it also results in large gains in earnings and living standards years after children receive treatment.
Policy Lesson 2: Free deworming treatment through school systems is a proven approach. Seeing as treated children may rapidly become reinfected by others, deworming treatment must be administered widely for maximum effectiveness. Leveraging the existing educational infrastructure helps minimize the cost of delivery per child and maximise the reach of the programs.
Policy Lesson 3: Scaling up school-based deworming should be an urgent policy priority. Among interventions that have been rigorously tested by randomized evaluations, school-based deworming is one of the most cost-effective means of increasing school attendance. The two drugs used in the Primary School Deworming Project, albendazole and praziquantel, cost approximately 4 cents and 18 cents per annual dose, respectively. Incorporating the costs of delivering and administering the treatments, J-PAL estimates that each year of additional schooling gained through the PSDP cost only US$7.19. That works out to almost 14 additional years of education per US$100 spent. This calculation is based on a small-scale implementation through an NGO; a large-scale national programme would likely cost even less per child and hence would be even more cost-effective.
The informative and thoughtful presentation by J-PAL was followed by a fruitful discussion between members of the audience and the J-PAL team. A representative from the National School Feeding Programme was able to talk through the design and implementation of their programme. The importance of micronutrients was discussed as well as the results of a study that has combined the three elements of deworming, feeding and micronutrients. Insight was also given by a local school nurse about the day-to-day logistics of the deworming programme in South African schools. The practitioners in the audience agreed that parental involvement remains a challenge with frustration around needing separate consent forms for every single administration of the deworming tablet. A promising connection was also made between a representative from the Department of Basic Education and the J-PAL team to provide links to Kenya and India policy makers for their input.
We look forward to hosting the J-PAL team for another important information-sharing conversation on Thursday 25th September on “Incentivising teachers to improve teacher attendance and practices”.