Making a Difference: Bridging the Gap in Quality Healthcare Access for School Children From Urban Slums in Karachi, Pakistan

Public health initiatives worldwide emphasize health equity, yet health disparities persist, particularly among children and adolescents [1]. Health equity is a core principle in the American Academy of Pediatrics' agenda for children [2]. However, achieving health equity remains a significant challenge, especially in developing countries. Children from low-income communities experience numerous disparities, including health conditions (e.g., malnutrition, oral health issues) and limited access to healthcare services. To address these health equity issues, school health services (SHS) represent an effective strategy for reducing health disparities among children. Schools provide students with opportunities to acquire knowledge and develop essential life skills for a promising future [3]. Health issues such as vision and oral health problems, malnutrition, obesity, chronic stress, risk-taking behaviors such as aggression and violence, and substance use are associated with low academic performance [2]. This link was demonstrated in a study conducted in Pakistan, which identified a significant association between malnutrition and poor academic outcomes [4]. Conversely, good health among school children leads to reduced drop-out rates, higher educational attainment, and better employment prospects [5]. Moreover, school children are exposed to various risks, including physical harm, violence, illnesses, and mental health issues. Therefore, creating a nurturing school environment is imperative to support a child's health and well-being. This makes schools a unique platform for preventive interventions and primary healthcare services, particularly for establishing a strong foundation of healthy behaviors that promote lifelong health. International organizations such as the World Health Organization (WHO), United Nations International Children's Emergency Fund (UNICEF), and United Nations Educational, Scientific, and Cultural Organization (UNESCO) have recognized the importance of schools in promoting children's health [6, 7]. In 1995, the WHO launched the Global School Health Initiative to advocate access to health services in schools. SHS, as outlined in this guideline, refers to comprehensive primary health care services provided by healthcare professionals to students, either on school grounds or at external healthcare facilities [3, 8]. These services include first aid, mental health care, counseling, immunizations, health education, and health promotion [9]. The value of SHSs is recognized worldwide, although practices vary across regions. The Community Preventive Services Task Force of the United States (US) government recently recommended the implementation of SHSs in low-income communities across the US, highlighting their cost-effectiveness and positive impact on various health outcomes [1]. While developed countries have acknowledged the positive outcomes of SHSs, many developing countries have failed to implement them effectively due to constraints such as a lack of funding and insufficient government support [9]. In Pakistan, school clinics have been part of the government's health infrastructure since 1952; however, in practice, there remains a significant gap in the actual implementation of SHS [9]. In 1980, Pakistan SHSs were expanded by appointing dedicated physicians, but the program lacked a comprehensive approach. Other initiatives, such as the Punjab Health Sector Reform Program (PHSRP) in 2008; the School Health Program by the National Commission for Human Development; and the School Health Program by the Pakistan Federal Ministry of Education in collaboration with UNESCO in 2010, were primarily donor-funded, making the long-term sustainability of these programs a significant challenge [6, 10-12]. Furthermore, Haider et al.'s [6] study identified additional barriers to the implementation of SHS in Pakistan, including inadequate infrastructure, limited community engagement, insufficient government support and funding, poor monitoring, lack of inter-sector collaboration, and absence of legislation and policy frameworks. Therefore, SHSs in Pakistan remain in the early stages of development and have not been fully integrated into existing school systems [9]. According to the Pakistan Education Statistics 2021/2022 [3], there are around 300,000 schools in Pakistan. Of these, 56.2% are public and 43.8% are private. Furthermore, the Pakistan Economic Survey 2015/2016 reported that approximately 40 million children are enrolled in schools in Pakistan, representing one-fourth of the country's population [9, 13]. Among them, around 53.5% are enrolled in public schools, whereas the private sector has an enrollment of 46.5%, making schools a key setting for reaching children across all social strata. Children from low socioeconomic status (SES) are typically enrolled in public schools, whereas those from high and middle SES attend private or mixed public-private schools [14]. The presence of school clinics in publics schools across Pakistan is limited. In 2008, the PHSRP revived the school clinics' development program, resulting in the rebuilding of school clinics in public schools across Punjab province [11]. However, school clinics have not been established in other provinces of Pakistan [13]. Meanwhile, in the private sector, some schools do offer health services; however, these often do not comply with standardized school health guidelines [9, 13]. Therefore, there is an urgent need to promote SHSs in both public and private schools across Pakistan. SHS remains an underprioritized component of the primary healthcare sector in Pakistan [13]. Despite efforts by both private and government organizations, significant disparities persist that hinder the delivery of quality healthcare to children, particularly those from underprivileged groups. A study conducted in Pakistan demonstrated inequities between the poorest and the richest population groups, highlighted by a higher prevalence of malnutrition among rural and urban poor populations, underscoring the need to implement child health policies that prioritize disadvantaged populations [14]. Another study identified that children from rural areas or those with lower levels of parental education had poorer oral health and hygiene habits [15]. This highlights the need to ensure access to healthcare services for children from all socioeconomic backgrounds, especially those from low-income settings, to improve outcomes across multiple health determinants. Recognizing this, SHS—a novel, ambulatory, and cost-effective program—was launched by a private tertiary care hospital in Karachi, Pakistan. Its primary goal is to bridge gaps in access to healthcare by providing free health checks, including physical health, mental health screenings, counseling, and health promotion to school children from low-income settings. Prior to conducting school visits, permission is sought from the school administration, and written, informed assent and consent are obtained from students and their parents or guardians before conducting the health screenings. To integrate these health checks into the school system, the visits are carefully scheduled to avoid disrupting classroom activities. Moreover, confidentiality is ensured by conducting health checks in a private area within school premises, designated by school administration. The secondary data obtained from these comprehensive health screenings will provide valuable insights into the prevalence of clinical abnormalities, mental health issues, health trends, and practices among school children in Karachi, which could inform similar initiatives elsewhere. Additionally, children who require prescriptions or referrals to specialized healthcare facilities are sent either to collaborating physicians, who have agreed to see these patients free of charge, or to government-run established hospitals. This ensures the timely management of serious or complex health conditions and helps prevent potentially fatal complications. This program also aims to empower schoolteachers to make a meaningful impact by promoting health education, encouraging healthy practices, and fostering a safe environment for learning and development. Furthermore, since teachers are often the first-line caregivers for children in schools, the program aims to train them in first aid so they can respond appropriately to medical emergencies [8]. By analyzing common health issues among students, the program aims to introduce targeted interventions on a broader scale. Identifying these health issues may also drive curricular changes, promote the inclusion of first aid training in teacher training programs, and foster a well-rounded approach to student well-being while encouraging the adoption of positive health behaviors among school children [8]. Moreover, the program could pave the way for the establishment of permanent SHSs across schools in Pakistan. Furthermore, it may also prompt government action to address prevalent health challenges among school children by advocating for changes in school health policies, ultimately shaping a healthier future for the country. This is the first initiative aimed at providing SHSs to urban poor school children in Karachi, Pakistan. Historically, governments at all levels (central, provincial, and local) have not taken responsibility for implementing SHSs, particularly in low-income communities, instead relying heavily on donor agencies to initiate such programs. These agencies often discontinue services once their funding period ends. To ensure sustainability and facilitate replication of the program, we designed it around minimal funding requirements, focusing on procuring medical equipment at a budget-friendly cost. By doing so, we aimed to advocate for its large-scale adoption by the government. Moreover, the quality of the health checks is maintained, as they are conducted by senior, experienced pediatricians, supported by trained nurses and research staff. This enables the collection of robust clinical data that could help to identify student health issues relevant to the local context. However, we encountered several implementation challenges, such as inadequate infrastructure in participating schools, including poor sanitation, improper waste disposal, poorly ventilated and overcrowded makeshift areas designated for health checks; a lack of trained teachers and staff competent in delivering health promotion; and the unavailability of first aid boxes or first aid medicines in schools. To mitigate some of these challenges, we advocate for the development and implementation of a national school health policy and legislation by the government, extending to all public and private schools. Under this policy, there is an urgent need to develop a school health curriculum that promotes the learning of social skills, physical health, and the importance of a safe and hygienic environment. Moreover, schoolteachers and students should be empowered to raise awareness within their communities about health and hygiene, thereby encouraging the adoption of positive health-seeking behaviors. Additionally, we recommend the formation of school healthcare teams, either stationed on-site or as a visiting ambulatory unit operated by the government, comprising a medical officer and a trained nurse, equipped with first aid boxes and a designated sick room to oversee student health services [8]. This program has important policy implications for key student health promotion stakeholders: the government, donor organizations, schools, and healthcare workers. The government should play a leading role by providing support and funding for the implementation of SHSs across schools in Pakistan. Moreover, political advocacy and media campaigns in favor of these initiatives could help establish national school health policy and legislation [6]. Additionally, the government should help secure funding and technical assistance from national and international donors by establishing mechanisms for implementation, monitoring, and evaluation. Moreover, to ensure scalability across various school systems and settings, the government should initially pilot the SHS program in one district per province and then expand to more districts, eventually scaling it across all schools in Pakistan. To understand and overcome major implementation challenges, the government should perform frequent audits of the system. Furthermore, to facilitate the integration of SHS into existing school systems, the government should design incentive programs for schools that effectively implement comprehensive SHS [16]. School administration, as an important stakeholder, should provide infrastructure and resources, organize awareness sessions for students and parents on SHSs, and conduct teacher training in health promotion and education [6]. Finally, healthcare workers should be engaged to conduct awareness campaigns and foster public-private partnerships to supplement government funding. In conclusion, to transform SHSs in Pakistan, there is a dire need to develop evidence-based programs that actively engage stakeholders across the public and private sectors, including policymakers, education officials, healthcare providers, school administrators, and community organizations. Ensuring the sustainability and scalability of these programs requires a strong tripartite partnership: the education sector should lead in program ownership, the health sector must provide technical expertise, and both governmental and non-governmental organizations, alongside international agencies, should offer consistent external oversight and support [10]. Through such multi-sectoral collaboration, SHSs can be effectively implemented across Pakistan to improve children's health and well-being. The authors declare no conflicts of interest.