School-based deworming is a low-cost intervention that takes advantage of existing school infrastructure and trains teachers to administer deworming treatment—safe tablets—to all primary school students on dedicated “deworming days,” once or twice per school-year. Because the tablets are inexpensive relative to diagnosis, which requires analysis of a stool sample in a laboratory, the World Health Organization (WHO) recommends periodic mass treatments in areas where more than 20 percent of children have worm infections. Research by J-PAL affiliated professors Michael Kremer and Edward Miguel has shown that school-based deworming of students improved health and school attendance in Kenya. Subsequent research has shown that deworming also increased the percentage of girls who passed a primary school exam and attended secondary school, and increased hours worked for men who were in treatment schools as children.
The Scale-Up: Evidence leads to multiple school-based deworming campaigns in Ethiopia, India, Kenya, and Vietnam
In 2007, Michael Kremer and Esther Duflo presented evidence on the impact of school-based deworming to the Young Global Leaders Education Task Force at the World Economic Forum Annual Meeting in Davos, Switzerland. In response, Deworm the World was launched as an independent organization to coordinate technical assistance and advocacy efforts for sustainable, large-scale school-based deworming programs.
In 2009, Kenya’s then-Prime Minister Raila Odinga announced the start of the National School-Based Deworming Programme at the World Economic Forum Annual Meeting. The Programme is a collaboration between the Kenyan ministries of Education, Science, and Technology and Health. Kenya’s National School-Based Deworming Programme is now in its fifth year since being relaunched in 2011, consistently treating over 6 million children across the country.
In 2010, J-PAL hosted a conference with the Government of Bihar, a state in India, to share evidence on school-based deworming and other promising programs. Following these discussions, the Government of Bihar, with support from Deworm the World, launched a state-wide deworming campaign in 2011, which reached 17 million children. Other large-scale deworming programs in India were implemented in Andhra Pradesh, Delhi, and Rajasthan. In February 2015, the Government of India launched a national deworming program and in October 2015, India announced it had treated 89.9 million children in 11 states since the launch of the campaign. In February 2016, India’s school-based deworming program reached 179 million children ages 1-19. The campaign was implemented in 1.78 million public schools, private schools, and preschools across nearly all 29 states and seven union territories. In August 2016, a second round of treatment was implemented in states where high worm prevalence suggested a need for twice-annual treatment.
The Deworm the World Initiative is now a program of the nonprofit organization Evidence Action, which builds long-term partnerships and provides technical assistance to help governments launch, monitor, and sustain school-based deworming programs.
Incorporating best practices from India and Kenya, the Government of Ethiopia also launched a national school-based deworming program in 2015, with support from partners including the Deworm the World Initiative. The program aims to distribute more than 100 million treatments in all endemic areas by 2020.
In 2016, the Deworm the World Initiative began supporting treatment in Nigeria and Vietnam, collaborating with implementing partners of deworming programs in Cross River State in Nigeria and four provinces in Vietnam. In the first year, the programs aim to reach over 500,000 children in Nigeria and 700,000 children in Vietnam.
The Problem: Worm infections affect health and school attendance
The WHO estimates that over 870 million children are in need of treatment for intestinal worms, which are transmitted through contact with water or soil contaminated with fecal matter. Worm infections can reduce the absorption of nutrients in the body, leading to anemia and malnutrition, and weaken the body’s immunological response to other infections such as malaria. Infected children may become too sick to attend school or too tired to concentrate in class. Because intestinal worms are most prevalent in poor countries where diagnosis is relatively costly, the WHO recommends periodic mass administration of anthelmintic drugs to groups of people in worm endemic areas. Oral deworming drugs are extremely effective with a single dose, at a cost of a few cents per tablet, and are safe for those without worm infections. Periodic administration every 6–12 months addresses reinfection and the health problems associated with high wormload.
“Intestinal worms are pervasive in the developing world and can have devastating effects. But there is growing awareness about how easy and inexpensive it is to treat worms, as well as surprising longer-term socioeconomic benefits. Research shows deworming to be extremely cost-effective: you get a lot of bang for your buck.” The New York Times, Fixes blog. April 2012
The Research: School-based deworming improved school attendance in the short term, productivity in the long term, and benefited neighbors and siblings
From 1998 to 2001, Michael Kremer and Edward Miguel evaluated the Primary School Deworming Project in Kenya. This program provided deworming tablets for soil-transmitted intestinal worms and schistosomiasis, as well as an instruction on how to avoid worm infections, to children in 75 primary schools in rural Busia, Kenya. At a cost of less than $0.60 per child per year, school-based deworming reduced serious worm infections by 61 percent and reduced school absenteeism by 25 percent. There were positive spillovers to children from reduced disease transmission among untreated children within treatment schools and for children who attended schools within three kilometers of treatment schools. Unlike previous studies, researchers quantified these spillover effects and showed that previous studies had underestimated the benefits of deworming.
“Evidence from recent rigorous studies in three different contexts suggests substantial impacts of childhood deworming on school participation, cognition and test scores, and adult labour market outcomes.” Vox CEPR’s Policy Portal, August 2015
A long-term follow-up found that deworming also improved school performance and future earnings. Deworming led to large academic gains for girls, increasing the rate at which girls passed the secondary school entrance exam by 9.6 percentage points over the comparison group mean of 41 percent. Men who were dewormed as children worked 3.5 more hours per week, spent more time in entrepreneurial activities, and were more likely to work in higher-wage manufacturing jobs than their untreated peers.
In our Student Participation cost effectiveness analysis, we estimate that school-based deworming adds 14 years of education per US$100 spent. 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.