The delicate balance of funding research and development of treatments for rare disease is only imperfectly achieved in Europe, and even the current provisional equilibrium is under a new threat from well-intentioned policy changes now in prospect that could—in addition to the intrinsic complexities of research—reduce the incentives on which commercial activity in this area is dependent. The European Union review of its pharmaceutical legislation, for which proposals are scheduled to appear before the end of 2022, envisages adjusting the decade-old incentives to meet objectives that are more precisely targeted. However, researchers, physicians, patients and industry have expressed concerns that ill-considered modifications could have unintended consequences in disrupting the current balance and could reduce rather than increase the flow of innovative treatments for rare diseases. It is an established policy in Europe that “patients suffering from rare conditions should be entitled to the same quality of treatment as other patients,” as the EU Regulation (EC) No. 141/2000 on orphan medicinal products states . The conThere is no doubt that the therapeutic landscape has already been dramatically improved by the 2000 regulation. The investments and efforts it incentivised with its EU-level mechanisms for orphan drug designation, and the accompanying benefits of some marketing exclusivity and reduced fees, have helped the emergence of effective treatments for rare diseases ranging from haemophilia to Gaucher, and from rare forms of cancer, pulmonary hypertension or neonatal diabetes to paroxysmal nocturnal haemoglobinuria—as many patients and their carers can testify. Over the last two decades, rare disease research has resulted in the grant of orphan status to some 2000 products, and the approval of more than 150 orphan drugs—compared with just eight therapies for rare diseases available before the adoption of the regulation ,8,9. At However, the successes to date should not be allowed to mask the gaping unmet need across the 6000 conditions currently classified as rare diseases ,15,16 anNonetheless, the EU’s own pharmaceutical strategy highlights the need for a review of the system to improve the delivery of treatments that respond to unmet need, and it recognises explicitly that some form of incentivisation or compensation is appropriate for medicines for rare diseases that pose challenges, both in terms of science and manufacturing ,20,21,22To add to the challenges of developers of orphan medicines, they must surmount not just the European regulatory hurdles of winning orphan designation and product approval but must also then find their way through a maze of differing national conditions . These pThis diversity is demonstrable simply in comparing across the member states provisions and the specific benefits—where they exist—for orphan drugs: in Austria, Finland, Hungary, Ireland, Latvia, Luxembourg, and Sweden there are no national benefits available. Additionally, in Austria, the reimbursement authority even makes it harder for orphan drugs to prove a patient benefit, because it interprets as a lack of evidence any deficiencies in endpoint data due to fast-track approvals or studies that have been cancelled for ethical reasons . In ItalAmong the benefits, orphan medicines qualify for exemption from the national tax on pharmaceuticals and clawbacks in Belgium, and pricing and reimbursement is faster . BulgariThe Czech Republic waives administrative, regulatory, and scientific fees, and Denmark offers some waiver of annual fees. France exempts orphan medicines from sales tax, some turnover and other taxes, and from fees on scientific advice. Greece offers a faster and easier pricing and reimbursement procedure. Hungary operates a named patient basis for funding of orphans, but the procedure is very administrative and time consuming. There is no separate reimbursement pathway in Ireland for orphan medicines, and the usual templates are judged by industry to be not fit for purpose . Italian legislation has always protected the experimentation of orphan drugs and their entry into the market to guarantee patients access to the best therapies available. Italy provides some tax breaks, exemption from clawbacks, and fee reductions, along with a faster pricing and reimbursement procedure and a dedicated fund for unauthorised orphan drugs awaiting approval. In particular, Law no. 648/1996 allows the supply of some drugs, paid for by the Health National System, to promptly respond to pathological conditions . FinallyIn Latvia, only some orphans are reimbursed, while Luxembourg allots prices in line with those of the country of origin. Malta offers 70% fee reductions for academic trials, and the Netherlands possible tax reductions for R&D by high-tech start-ups, as well as some fee waivers and reductions. Poland offers theoretically faster pricing and reimbursement for drugs categorised as innovative drugs. In Portugal orphan drugs are taxed only at 5% and a special use authorisation procedure provides access to some of them. Romania prioritises assessment of pricing dossiers for orphans, Slovakia and Slovenia offer easier reimbursement, and Spain imposes a lower mandatory rebate on orphan drugs . However, the very diversity among these benefits (and limitations) demands intricate study by drug companies as they construct their development strategies, which can compound the precarity of the case for work on orphan drugs. Already, the pathway is littered with obstacles: lack of disease knowledge, novel or unproven surrogate endpoints, and small and highly heterogeneous patient populations—all of which impact R&D time and amplify the risk of trial failure compared to more common, better understood conditions. In addition, small patient populations limit the revenue potential of products that successfully reach the market ,42,43. THowever, the impact of the numerous challenges for developers on economic viability—as outlined above are inevitably a major consideration of companies evaluating their investment priorities. Manufacturers compare investment propositions across products and disease areas, and investors weigh options across industries. Investment in the orphan space remains a marginal economic decision in most cases; the economic case for investment, is on average, weak, even in the presence of the incentives in the current regulation. For investment to continue, the risk-adjusted return needs to be commensurate with that from other types of medicines or alternative investment. As a result, legislative provisions have been created aimed at mitigating the market failures linked to low-prevalence, high unmet need conditions , in a stRevision of the incentives for orphan drugs will balance competing objectives if it is to be successful. The EU must of course take account of the ambition to maintain economically sustainable health systems and respond to the many concerns over high prices for many orphan drugs . At the However, unofficial indications that emerged in early 2022 of EU thinking on the changes now planned suggest that vital elements in the current incentive schemes could be drastically impaired—in terms both of eligibility for the scheme and of conditions attached to the benefits it confers. These rumoured tightenings of the calculations of disease prevalence for qualifying, on the duration of a designation, or on the length of market exclusivity granted to authorised orphans are seen by defenders of orphan medicines as serious potential disruptors of the delicate economics of investment in development.The central conclusion is that in a competitive context for choice of what and where to support financially, a causal relationship exists between incentives and investment. There can be no presumption of R&D in rare diseases, because it is intrinsically uneconomic . The EU Some of the mechanisms in the regulation are under more threat than others. In particular, there is a belief among some policy makers that companies are unduly exploiting the provisions covering multiple indications, notably in the field of oncology, and they seek to limit the corresponding market exclusivity. Under current rules, when an innovation in a rare disease is discovered also to be efficient in another rare disease, it keeps its orphan designation when the second indication is also approved for that other rare disease . This haThe argument is made by critics of the incentives scheme that the industry is being disingenuous when warning that lower prices or lack of incentives are linked to delayed launch in particular countries or regions. There is evidence, however, from industry-commissioned studies that the pattern of delayed launch is consistently observed in countries and regions with low prices and barriers to reimbursement. The average delay between market authorisation and patient availability for orphan drugs can be as short as 3.5 months in some countries or as long as 3.6 years—and the countries that suffer the greatest delay are typically in eastern Europe and the Baltics. In total, 25% of countries studies do not have availability to any non-oncology orphan drugs approved in 2020, and 30% of countries studied have availability to less than 10% of the non-oncology orphan drugs approved between 2017 and 2020 . The comWith the increase in the number of approved drugs for rare diseases, the high prices associated with some of the medicines have come into focus of discussion. In a detailed study published by Jayasundara et al., comparing the differences in clinical costs between orphan and non-orphan drugs, they found that out-of-pocket clinical costs per approved orphan drug were USD 166 million, while for a non-orphan drug they were USD 291 million. Moreover, the capitalised clinical costs are also lower for approved orphan drugs than for non-orphan drugs. It may be that the high prices of drugs for rare diseases allow drug R&D and manufacturing costs to be reimbursed from a relatively small number of patients. For both groups of drugs, out-of-pocket costs increase with the clinical trial phase, and therefore, according to this whole perspective, healthcare costs could be better regulated, at least on the basis of research and development and production costs to ensure that the patients have access to the best care ,59,60.The future of research depends on greater differentiation of pathologies, identification of new sub-pathologies, and the provision of ever better adapted treatments to deliver better clinical outcomes ,53,61. IThe benefit of market exclusivity also faces a challenge of enforceability at member state level, and this has the effect of discouraging continued investments to develop and launch new indications for an existing orphan drug ,63. The The conclusion to be drawn from these observations is that the revision of the incentives in the orphan drug regulation needs to be conducted with caution, and in full understanding of the dynamics influencing drug development. If the EU were to bow to the evident pressures for reduced incentives, it would disrupt what is already a tenuous equilibrium in European development of orphan medicines. The EU might, instead, contemplate promoting a well-informed and broadly accessible discussion of the factors governing orphan drug development. The real risk is not that there will be no more orphan medicines, but there may be no more orphans launched in Europe, because the economic viability of European engagement—with a combination of low prices and insufficient incentives—would be jeopardised. European investment would move away from rare diseases, and the development of orphans would gravitate to regions where incentives and prices offered better compensation for the additional risks of orphan drug development. Additionally, where prices are higher—the US being the most obvious example—and at a time when the trend is inexorably towards international reference pricing, orphan drug developers may hesitate to launch in lower-priced regions for fear of contamination of their higher prices .European society’s goals for equitable access to treatments will be met only if the economic incentives are right, if they provide for the prospect of profit to reward investment decisions and inform go/no go calls as a potential medicine emerges. For orphans, with smaller commercial opportunities, this calculation is still more acute, and market exclusivity and price need to balance the equation. Lower prevalence needs compensation through higher prices and/or compensating incentives. Maintaining a positive incentive framework is essential to advancing therapeutic innovation towards effective preventative medicines and treatments for rare diseases, strengthening equitable health systems, and fostering a productive biopharmaceutical industry in Europe. If the EU is indeed to revise its incentives for orphan drugs, 2022 could be the crucial year for ensuring that it tips the right way.


Suicide is a global health issue that needs to be addressed. The COVID-19 pandemic has resulted in an increased mental health burden. Stigma has obstructed efforts to prevent suicide as individuals who need urgent support do not seek appropriate help. The influence of stigma is likely to grow in tandem with the COVID-19 pandemic. The stigmatization of persons with mental illnesses is widespread worldwide, and it has substantial effects on both the individual and society. Our viewpoints aim to address the probable link between stigma and suicide in the wake of the current pandemic and propose ideas for reducing suicide-related stigma. Suicide is one of the leading causes of death globally, with this trend being more pronounced in younger people and low and middle income countries (LMIC). According to the World Health Organisation (WHO), over 77% of suicide deaths worldwide occur in LMIC, with more than 700,000 suicide deaths reported in 2019 and 173,347 in India alone  are in the frontline; they play leadership roles in health care development and suicide prevention . They haTherefore, ECPs need to have a prominent role in the fight against COVID-19 and suicide-related stigma, informing, teaching, promoting research, and influencing public policies . This caOrganizing support networks for at-risk individuals may provide powerful stress-buffering effects at an interpersonal level . EducatiFinally, targeted interventions and a collaborative approach are required at various levels: individual, community and governmental. Suggested recommendations at each level are provided below in The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.SS conceptualized and wrote the first draft. All other authors contributed equally to critical revision and writing of the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Anthropocentric activities have induced climate change, threatened planetary health, and harmed human health and wellness. The changing lifestyles, dietary patterns and digital obsession have affected the mental and physical health, particularly of the youth. University campuses reflect the challenges faced by the society at large and therefore make for an ideal ecosystem to initiate positive changes toward wellness and sustainability. The energy of ~200 million university students globally is largely unleveraged for facing these challenges. Values of empathy and sustainable living are crucial to be inculcated, alongside technical and managerial skills for leading the mass transformation. This article describes a novel pedagogic approach called the University Wellness Program (UWP). The aim of UWP is to equip students with technical and leadership skills to achieve wellness and campus sustainability. That is, UWP is a platform that facilitates the students to design and implement multi-disciplinary projects that address campus related challenges. In the process, they acquire the necessary soft and technical skills to solve real-life problems. The durability of UWP is secured since the projects and activities are explicitly linked to existing curricula and evaluation system of the university. The strategy and framework adopted, and the early experiences of implementing UWP are shared. UWP is amenable for replication globally and has the potential to create change-makers. Human wellbeing is an outcome of complex, interrelated factors involving the individual, society, and the planet . These aAnthropocentric activities have adversely impacted biotic and abiotic environments, leading to unprecedented changes to climate . The latHuman lifestyle and dietary changes over the last 3–4 decades have seen a steady drop in mental wellbeing and an increase in respiratory and metabolic diseases, cancer, and injuries , 8. An aOther man-made challenges that threaten the future of mankind largely stem from inequity . These iAround 3.5 billion young adults (<30 years of age) live in this world, which amounts to almost 50% of the total global population . Of theswithin the academic systems of universities. The University Wellness Program (UWP) is one such pedagogic innovation that evolved independently within the milieu of a typical Indian university. This article describes the UWP concept, genesis, the pedagogical framework and the process adopted. It shares the initial experiences and challenges faced.The concept of Health Promoting Universities and a framework for integrating health in curriculum and university system was proposed in 1998 by academicians in the UK . The Okato existing curricula and evaluation system of the academic programs in the university. UWP provides the scope for empathy, inclusiveness, reflection, ideation, collaboration, and leadership. Over time it is expected to create an ecosystem of empathy, equity, and value for fellow beings and the planetary resources. The students also become equipped with the necessary practical skills and competencies to tackle real-life problems when they graduate and become future global citizens.University Wellness Program (UWP) is an experiential learning platform that encourages students to think, design and implement multi-disciplinary projects for the benefit of the university community. The twin goals of UWP are (i) to achieve wellness and campus sustainability and (ii) to equip students with technical and leadership skills. The vision of UWP is ambitious and its durability is addressed by explicitly linking all its projects/ activities There were three main thought processes that led to the genesis of UWP during 2019 .The National Crime Records Bureau (NCRB) reported that young adults in the age group of 18–30 years was the most vulnerable, contributing to >35% of suicides in India. It was very disturbing to note that every hour one university student succumbed to suicide in India , 28. GloUniversity freshers struggle to adjust to academic challenges, new environments, and relationships. Facing these challenges requires a positive mental framework and resilience. Moeller et al., point out that emotional and social quotients (EQ and SQ) play an equal role as the intelligent quotient (IQ) in a student's academic performance . EQ and ad hoc manner and become yet another indicator in the university ranking system. For any effort to become embedded in the system and to change the mindset and behavior of the stakeholders, requires a parallel, contextual, bottom-up approach as well, involving the key stakeholders, along with programmatic interventions that are sustainable by design . The graduating students need to also be prepared to face the global challenges of climate change, conflicts, and disasters. While being sensitive and empathetic to societal issues, the graduates need to develop the technical and leadership skills to address these challenges. It was reported that almost every other university graduate from Indian universities in 2018 did not have the necessary skills . PracticHigher education is not just for better jobs and pay packages for the graduates but also to create thought leaders and change makers for human development and a sustainable future . A studyThus, with enough complex issues on campus, a university would be an ideal place to implement UWP.individual's perception of being well. The feeling of “being well” is important for carrying out routine functions and in living life to the fullest. One can clinically be perfectly “healthy” but still not feel “well”, while another who has serious health problems can still “feel” well, enthusiastic, and active. Wellness is dynamic and dependent on individual mind-set and the ability to bounce back from any obstacle.The commonly accepted definition of Health is that of WHO. Health is a “state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity” . In the Svasthya . That is, the state of being in harmony with one-self. This state would vary with person and context. It was felt that “wellness” may be a better terminology to be used in a university context than “health” or “healthy”. Therefore, the University Wellness Program or UWP was coined.The Global Wellness Institute defines wellness as “the active pursuit of activities, choices and lifestyles that lead to a state of holistic health”. That is, wellness can be aimed for and actively pursued . WellnesUWP being a new concept to Indian universities, the challenge was to create processes that aims to achieve wellness and campus sustainability through student learning and doing. The challenge was also to integrate UWP within the university system for better programmatic sustainability. UWP kick-started with an evolving strategy, following four broad steps as given in Almost all university academic programs have structured syllabi comprising of both theory and practicals/ practicum which usually have a one-to-one correlation, with the practicals strengthening theoretical learning. For example, a Chemistry student gets exposed to the theory of acids and bases during lectures, and learns better by performing acid-base titrations during practicals. These are absolutely essential and should continue. However, they are typically stand-alone, mono-disciplinary learning methods that most often are not linked to real-life, multi-disciplinary issues. The mainstream model of education at best produces students who learn, recall and predominantly practice mono-disciplines post their graduation. Schön  describeOne of the ways a broader application of theoretical learning can happen is by making UWP an integral part of existing curricula of the various academic programs. The methodology is iterative involving discussions with key stakeholders. The framework adopted to initiate UWP and early experiences have been shared in the following sections.Freeman's simple definition of “stakeholder” as “any group or individual that is affected by or can affect the achievement of an organization” is applicable in a university setting . UniversWithout the buy-in from key stakeholders, any new program can run into multiple roadblocks during implementation. Therefore, one of the essential steps to be taken before initiating any program is to obtain the buy-in from key stakeholders, particularly from the top management during the initial stages .In the case of UWP, sharing the vision, objectives, and scope helped gauge the readiness of the different stakeholder groups to adopt the program and to enthuse their participation. It also helped garner the necessary administrative, financial, and human resource support from the management to initiate the program. Meetings with the faculty and heads of departments provided an opportunity to brainstorm ideas, learn about ongoing initiatives on sustainability and wellness, and the major implementation challenges faced. Interactions with student groups were useful in providing insights into the kind and intensity of issues on campus and assessing the capacities and interest of students. The faculty and students at the School of Public Health (SPH) were the immediate stakeholders, who in turn carried the UWP agenda forward.Management by Objectives that describes the importance of all stakeholders to participate in defining the objectives for a program's viability and durability  and Undergraduate (UG) academic programs at the University run on a semester basis and therefore it was decided to set semester-wise (5 months) objectives. Brainstorming meetings with the management, faculty and students were held before crystallizing the objectives for UWP for the first semester. Two mini projects were undertaken by the students and faculty of SPH, for the first semester (August–December 2019):Mini Project #1: Launch of UWPIn order to announce UWP, it was decided to hold a formal event inviting high profile individuals, the top management, heads of departments, faculty and students on campus. It was also decided to invite the media and press for giving the event good visibility.Mini Project #2: Identification of key student issuesStudents were the largest (~60–70%) stakeholders on university campus. Hence it was decided to identify issues of this group, to begin with. It was important to know the status of wellness of the students, the key issues faced by them and the coping methods.The framework and processes were crystallized and documented for initiating the two mini- projects during this period.Practice-based learning is an essential part of the pedagogy of professional academic programs. For example, a student training to be a doctor, dentist or a nurse is exposed to patients on a regular basis, so that they learn how to treat patients when they become full-fledged practitioners. This is not the norm in other disciplines and the students are rarely exposed to wellness or sustainability concepts and actions.The UWP idea is to encourage students to look inward, within the campus and their immediate environments including the communities, to identify and address the issues, leveraging their respective domain skills. For example, a Visual Communication student from the Humanities and Sciences College, who learns the skills in photo/video-graphy, drawing, computer graphics, recording etc. and a public health student from the Health Sciences College, who learns health promotion, communication, nutrition, and research methods etc. as a part of their respective academic syllabi, can work together to identify the nutritional status of students on campus and to create effective health promotional materials. This collaboration would bring about a better researched audiovisual and there would be a cross-fertilization of ideas. Thus, the practical application of theoretical learning will be for achieving overall campus wellness.Once the aim is stated, designing the UWP projects three main steps were involved :Detail the activities: Once the objective(s) of the project were set, the broad activities that would be required for fulfilling the objectives were delineated. For example, we wanted to create and inaugurate a logo for UWP during the UWP launch event, which meant designing the logo was one of the UWP activities under Mini-project #1.(i) State the Learning Outcomes: Identify the technical and other skills that are required to achieve the project learning outcomes. For example, knowledge about effective communication and branding, and skills to design a logo are some of the expected learning outcomes from Mini Project #1.(ii) Map and Select Modules: Select those modules from the syllabus whose learning objectives match with those of the UWP project outcomes. Leverage modules that provide the space to learn hands-on technical skills and/or soft skills required to achieve the targets ((iii)  targets . The modexplicitly spelt out as “learning” outcomes and tagged to pertinent module(s), and the students were formally evaluated for the same. Sometimes when the targets set required multi-disciplinary efforts, it was important that departments within or outside the college collaborate to achieve them.Broadly, the skills and competencies required for implementing the Mini-projects were While Mini Project #1, namely the UWP launch, was an event that required branding, networking and managerial skills, Mini Project #2 (Identification of key issues) required mainly research skills. In consultation with the SPH team of faculty and students, plans were developed.The groups, the milestones, end points, timelines and responsibilities to implement the two mini projects, were written down and shared with all. The PG and UG students across all years and programs, were vertically grouped. That is, a I year UG student who was freshly out of high school got to observe and learn from the final year senior PG students, and the seniors in turn learnt empathy and tolerance. The students selected one leader/representative from each group and one faculty volunteered to drive each of the UWP projects . The maiStudents were trained and guided on the technical skills and competencies required to execute the activities. The faculty handling the module(s) has the liberty of selecting the aspect(s) for which training is required and this would depend on the set objectives and activities. It may or may not be the regular training provided. For example, as a part of the ‘Social and Behavioral Change and Effective Communication’ module, a professional creative designer was especially brought in to conduct a workshop on the importance of brand building. The students learnt the essential features of branding for public health. Creating a logo for UWP was given as an assignment for which they were evaluated and the team which designed the best logo for UWP was to be rewarded by show-casing it at the UWP launch event. It was declared that in recognition of the students' participation, certificates for leadership and contribution would be distributed.The theoretical aspects of the principles of Research Methods , protocol design, ethics, data collection, analysis and interpretation etc are taught as a part of the regular teaching of the module. However, practical training was also provided on qualitative research including performing Free Listing, Focus Group Discussions (FGDs) and analysis of qualitative responses, which were essential skills to fulfill Mini-Project #2.Students were oriented in soft skills including listening, team work, tolerance and public speaking as a part of the “Social and behavior change, effective communication in healthcare” module. They were nudged to reflect on the process and recommend next steps.Thus, over and above the regular teaching, special training was given depending on the skills and competencies required for fulfilling the project. It may vary depending on the project requirement.For durability of UWP it is important to leverage existing university evaluation system and integrate the student projects within its scope. For example, in our university system 40% of marks is toward continuous internal assessment and 60% allocated for end-semester examination. The internal assessment system provided adequate scope for evaluating the practical learning of the students in the UWP projects. Normally, assignments, presentations and cycle tests on theoretical learning are evaluated in internal assessment. For UWP, execution of project activities and deliverables became part of the existing continuous, monitoring and internal assessment system of the module(s).Students were evaluated for individual as well as group contributions for the fulfillment of two projects. Soft skills such as leadership qualities, communication skills, empathy, inclusivity and teamship were encouraged and assessed based on class interactions and presentations during the semester. The projects themselves were evaluated by the success of fulfilling the objectives, namely UWP launch event and prioirtization of key issues faced by the students. We are in the process of creating the framework for evaluating UWP at the university level. Five year goals, roadmap and key success indicators are being developed.Research and action projects, events and activities are a regular part of any univerisity. However, keeping in mind the UWP objectives and durability, a set of criteria were developed by us. Only those projects/activities that fulfilled these criteria were qualified as a UWP project/activity.the purpose/objective has to be clearly spelt out and should contribute to wellness and/or campus sustainability(i) the expected outputs/outcomes stated- these could include products/service/events etc. Other practical/soft skills learnt need to also be indicated(ii) the student academic program/modules and evaluation methods that will be leveraged need to be mentioned(iii) the faculty in-charge who will drive the project/activity, needs to be named(iv) name the student leader and team(s) who will execute the project, need to be named(v) the skeletal plan of execution needs to be secured(vi) A project was considered successful if the set objectives and learning outcomes were achieved, fulfilling the above criteria.UWP was successfully launched at an official event organized on November 12th, 2019, and the best logo for UWP that was designed by students was unveiled at the event . The groThe students received hands-on experience in conducting qualitative research under the Research Methodology module . They le➢ Mental Wellbeing—stress, anxiety, depression and suicidal ideation thoughts etc emerged as important emotions that affected the students daily performance. Girl students specifically mentioned pre-menstrual syndrome (PMS) as an issue➢ Lifestyle behavior—social media time, mobile usage, substance abuse, food intake, sedantary lifestyle, indisciplined sleep pattern etc. were ackmolwledged as significant aspects of student life on campus➢ Water, Sanitation and Hygiene (WASH)—campus WASH facilities were mentioned as being important. Frequent cleaning of toilets was expressed as important during busy times. The girl students mentioned that better and accessible facilities can be provided, to help during menstruation➢ Global Warming—It was important to note that global warming, in general, came up in the FGDs as an important issue that the students were concerned about. These included pollution, food wastage, transport, use of plastics and paper, within and outside the campus. The FGDs strongly highlighted that the students realized the negative impact of human (anthropocentric) activities on the health of communities and the planet. There was a will to contribute and make a differenceThe presentation of the research findings of the key issues faced by the university students at the UWP launch  was a highlight of the event and was much appreciated by the management and audience.Going forward, prioritization of projects and activities to be taken up needs to be worked out. This would depend on the urgency, resources available, and the interest of the students, faculty and management.The Okanagan Charter started the Canadian Health Promoting Campuses Network in 2015 that called for embedding health in all aspects of campus culture . The UK This article has introduced a new pedagogic concept called the University Wellness Program (UWP), which enables students to work toward achieving wellness and campus sustainability. Through the implementation of the two Mini projects, a methodology/framework has been delineated to demonstrate how UWP can be embedded in university learning and evaluation system. One project was to formally launch UWP and the other was to identify and prioritize key issues faced by students on campus.The UWP Mini-Projects provided the students hands-on technical skills, managerial, leadership and other soft skills to implement the projects. Over and above the technical skills required in implementing the projects, the students learnt listening skills, empathy, ability to think critically, leadership and team-ship, public speaking and effective communication. These qualitative aspects were monitored and assessed on a weekly basis by faculty. All teams and presented their work at the final project presentation, as college seminar. The best teams got opportunity to present at the UWP launch event.per se will become evident only over a period of time, say 5 years. A system for longitudinal research is being set up with the current cohort of students. A database is planned to be created for capturing every student's wellness at the university level. We have also established a core UWP committee consisting of experts and student representatives from different departments across the university to look at the various UWP aspects, including research/action/fund mobilization/management/communication related. The committee members are the drivers to keep UWP going. A 5 year roadmap for UWP is being created, with goals and key success indicators. Faculty and students of SPH and the Department of Computer Science & Engineering are creating a digital platform and a dashboard to capture the UWP projects and progress. This in itself was taken up as a UWP project. These are some of the work in progress beyond 2019.We expect that the impact created by UWP The expected outcomes from UWP over time can be classified as physical outputs, technical and soft impact, and societal impact . UWP wouThe seven factors identified by Valaitis et al., that influence the success of new or existing programs are very relevant for the durability of UWP . The facThe challenges faced in UWP implementation were mainly faculty and program implementation related. Initially, convincing the faculty about the idea took some time. The main reasons for this were (i) resistance to new ideas; as is usual in any pre-existing group (ii) lack of clear-cut methodology to integrate UWP in existing teaching and evaluation system in the early stages of UWP (iii) faculty perception as additional burden to already hectic academic and research schedules (vi) fear of failure and (v) indifference and hesitancy in ownership.UWP uses practice/problem-based learning (PBL) approach for achieving wellness and sustainability on university campus. PBL has the advantage of imparting capacities among students at the conceptual, practical and attitudinal levels but it presents challenges to the teachers. Loss of control over their teaching styles, selection of topics of students interest, unpredictability of outcomes, fear of exposure of their knowledge gaps and need for more time investment were some of the perceptions of teachers about PBL . These iRecruitment of a new Teaching Associate who is dedicated for UWP coordination helped immensely in reducing the faculty burden. The faculty buy-in was achieved through frequent meetings and interactions, setting objectives, drawing up clear plans of execution and engagement. Discussing the potential advantages, and outcomes motivated them a great deal.Identifying topics that were pertinent to key stakeholder issues, campus wellness and sustainability and designing research or action-oriented projects that leveraged existing academic programs required asking fundamental questions. For example, what are the key issues faced by students and the status of wellness of students? What needs to be done and how to crystallize them requires individual and group brainstorming. These were difficult to achieve in an already packed teaching-learning-evaluation university system. We solved these to a large extent by setting aside 1 day in a week for UWP related activities. Explicit linkage of objectives to ongoing modules and the freedom to assign practical work, can enhance the quality of teaching and learning. Also, a campus wellness/sustainability related issue gets addressed in the process.UWP members become potential stewards and change-makers in university campuses. The activities can also become part of regular clubs, roping-in students and faculty from departments and universities. New academic programs and PhDs could stem from the UWP projects. Toolkits and online/offline training programs can be developed for sharing with other universities. UWP is work in progress and the strategy would need to be modified depending on context.The article introduces University Wellness Program (UWP), a novel pedagogical concept to focus on wellness and sustainability issues that face us today. It provides the scope for practice-based learning for students, by leveraging existing academic modules and evaluation system. Our strategy demonstrates the feasibility of UWP. Faculty interest and leadership are probably the biggest assumptions for UWP's durability.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Inclusive early childhood intervention provides opportunities for children with disabilities to receive education with typically developing children. The present study examined the effects of the AI-AI STEP Program, which is designed to help nursery teachers learn the methods of inclusive early childhood intervention for children with disabilities. This study involved 37 managers of 37 nursery schools in Japan, 48 nursery teachers, and 48 children with disabilities. The school managers, who had previously learned about the program through a seminar we offered, provided the nursery teachers with guidance on the program. The guidance provided to the nursery teachers consisted of combined structured explanations with a manual and on-the-job training. The program was performed for 6 months, and changes in the children's development and behavior and the school nursery teachers' self-efficacy and state-trait anxiety, were examined before and after using the program. Multivariate analysis was used to assess factors that had an effect on the children's developmental gains through the program. The developmental quotient of children significantly improved. In addition, “emotional symptoms” and “peer problems” on the Strengths and Difficulties Questionnaire subscale markedly improved. The self-efficacy of nursery teachers significantly improved, and state anxiety decreased. There was a significant relationship between the improvement of the children's development quotient and a lower development quotient at baseline. The provision of inclusive early childhood intervention using the program promoted the children's development, and improved their behavior. Furthermore, it had a positive effect on the nursery teachers. Early childhood intervention (ECI) is a provision of support for children with disabilities according to their developmental stages. ECI is one of a variety of evidences suggesting that early childhood intervention provides an important opportunity to alter children's development and children-parent interactions –3. ChildIn Japan, IEI is defined as “education and care for infants with physical and/or intellectual disabilities provided in nursery schools.” In 1974, the Ministry of Health and Welfare  launched a project for children with disabilities to receive education and care in nursery schools. It was an innovative attempt to incorporate nursery schools, in addition to rehabilitation centers, into Japan's IECI system for children with disabilities. Currently, 92.7% of all Japanese nursery schools provide IECI for such children . These sIECI for children with disabilities in nursery schools is supported by experts through two types of service: on-site counseling and nursery school-visit services. The former is operated by municipalities that dispatch doctors, psychologists, or other experts to nursery schools, and provide guidance for nursery teachers. These experts directly advise nursery teachers about how to provide childcare to children with disabilities. In the latter, which started in April 2012, experts from the child developmental support centers visit nursery and elementary schools in communities to directly provide specialized support for children with disabilities.The Japanese government has recently begun to incorporate IECI into its general policies for children with or without disabilities. In April 2015, it launched the Comprehensive Support System for Children and Childcare by three central government entities: the Cabinet Office; the Ministry of Education, Culture, Sports, Science and Technology; and the Ministry of Health, Labor and Welfare. Importance was attached to close collaboration to simultaneously support children with disabilities and their parents. It is necessary to further organize systems to provide IECI for children with disabilities in nursery schools, and improve their quality; however, there are limited assessments of IECI and evaluation of its impact on children in Japan.Since 2004, the Aichi Children's Health and Medical Center has been training leaders of nursery teachers using the AI-AI STEP (Step TEaching Program) Program . The firWe examined the effects on target children and nursery teachers of the AI-AI STEP Program, and assessed factors that had an effect on the children's developmental gains through the program.The AI-AI STEP Program aims to support children's appropriate behaviors, focusing on their relationships with nursery teachers . The AI-The individualized approaches correspond to a target child's three behavioral stages: (1) behaviors to be developed (to perform self-care), (2) behaviors to be adopted (to overcome difficulties or acquire new experiences), and (3) behaviors to be avoided (problematic or possibly problematic behaviors). The nursery teachers focus on these behaviors and select a behavior from stage 1 that they consider to be easier to correct. The process has six steps: (1) observing behaviors, (2) setting three support processes, (3) practicing (making commitments), (4) recording, (5) assessing (grading), and (6) summarizing. When the target child can perform the behavior properly, the nursery chooses a behavior from stage 2 and supports the child using the same six steps. A nursery teacher starts with an easier task (stage 1), and proceeds to the more difficult tasks (stage 2 or 3). These three stages and six steps enable nursery teachers to acquire and improve their objective observation, practical, and verification skills.The grouping approaches are based on the idea that groups can be appropriately created by establishing favorable relationships between target children and nursery teachers, between target and other children, and between other children and nursery teachers, rather than by simply including target children in groups. Nursery teachers' behaviors are an exemplary for children at all times. The use of affirmations for target children by nursery teachers, such as praising them in front of other children, promotes the latter's affirmative behaviors toward the former. Such approaches are effective for other children to observe and develop appropriate attitudes toward the target children. They also promote affirmative behaviors and attitudes, such as ‘praising', among all class members.The present study was a pre-post design quasi-experimental study. This study consisted of 37 managers of 37 nursery schools in the Aichi and Fukushima Prefectures, Japan; 48 nursery teachers; and 48 children with disabilities. The school managers, who had previously learned about the program through an intensive seminar we offered, provided the nursery teachers in charge of the children with disabilities with guidance on the program at their nursery schools. The managers' guidance consisted of combined structured explanations with a manual and on-the-job training. Subsequently, based on the program and with support from the school managers, the nursery teachers provided IECI for the children with disabilities for 6 months. Fidelity assessments of nursery teachers' IECI were conducted by managers using direct observation and reviews of the nursery teachers' self-reports that were completed in steps 4–6. Before and after IECI using the program, changes in the children's development and behaviors, as well as those in the school nursery teachers' self-efficacy and state-trait anxiety, were examined.The children's development and behavior were assessed using the Kinder Infant Development Scale (KIDS)  and StreKIDS is a parent/caregiver-rated questionnaire for developmental screening of children aged 1 month to 6 years and 11 months that has been used since 1989 all over Japan . There aWe used the Japanese version of SDQ . The SDQThe GSES was developed by Sakano and Tohjoh . It is aSTAI, which was developed by Spielberger et al. , is a pst-test. Furthermore, multivariate analysis was used to assess factors that had an effect on the children's developmental gains through the AI-AI STEP Program. The number of children was small; therefore, in the multivariate analysis, the children's and the nursery teachers' factors were selected based on correlation coefficients of associations between each factor and the children's developmental gains.Changes in these items after intervention with the AI-AI STEP Program were examined using a paired We explained the study protocol to the school managers and the nursery teachers, then informed the parents of the children. The study was conducted with written informed consent from the school managers, the nursery teachers, and the parents of the children, and the approval of the ethics committee of the institution the first author belonged to (No. 599).n = 26), autism spectrum disorder (n = 10), intellectual disorder (n = 4), Down syndrome (n = 2), and physical disabilities (n = 2).p < 0.0005).Improvement of the children's development quotient was significantly affected by a lower children's development quotient at baseline, the diagnosis of autism spectrum disorder, and higher state anxiety inventory at baseline of the children's nursery teacher .The present study examined the effects of the AI-AI STEP Program to support IECI for children with disabilities on the children themselves and the nursery teachers in charge of them. The provision of IECI using the program increased the nursery teachers' self-efficacy and decreased anxiety. The nursery teachers had more confidence in their ability to address the needs of children with disabilities after the program. The program also promoted the children's development, and improved their behavior, in particular emotional symptoms and peer problems. The improvement of the children's development was larger for those children who had larger developmental delays or who had a diagnosis of autism spectrum disorder at baseline.As the children's developmental index values increased even when adjusting for chronological age, it was confirmed that the program promoted children's development. Improvements in children's language development and social adaptation ability were also reported in some previous studies , 9. The Among the nursery teachers, both state-related anxiety and general self-efficacy scores improved after starting to use the program. Most nursery teachers perceived providing IEI for children with disabilities to be challenging; therefore, the program may have reduced their anxiety through the learning of practical methods for education and care. In addition, the reduction in their state anxiety was more marked when their state anxiety was higher at baseline, suggesting that their anxiety was reduced by having school managers' support and realizing the positive effects of their own approaches on children. In a previous study that taught nursery teachers about health literacy , we observed that participating teachers who used the learned skills continued to have confidence in conveying health messages even 1 year after the training . Both prThis study has some limitations. First, the number of subjects was limited. Second, as the design of this study had a one-group pre-post design, it was difficult to clarify whether the effects had been achieved through intervention or as a result of child development. Furthermore, we were unable to ascertain whether the program directly influenced the nursery teachers' self-efficacy using their assessment results or whether other outside factors had an effect. Third, the children's outcomes may be overestimated because of differing perspectives among the teachers. Finally, the mechanism that led both the children and their teachers to change through the program remained unclear. The theoretical background and validation of the program were insufficient because it was a practice-based program. Thus, it may be necessary to use a control group in future studies or conduct randomized control studies with more detailed data collection from the both groups.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.KU, AG, TI, and YY: material preparation and data collection were performed. KU and AG: analysis was performed. KU: the first draft of the manuscript was written. All authors contributed to the study conception and design, commented on previous version of the manuscript, read, and approved the final manuscript.This study was supported by Research on Region Medical, Health, Labor and Welfare Sciences Research Grants (201232063A) by Japanese Ministry of Health, Labor and Welfare.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The finding of the study revealed that the schools were progressing well in access. However, there are variations of access rates from district to district and from school to school. The variations were determined by the commitment of the school leadership and the extent of community engagement in school matters. The study further identified the schools as inefficient which is manifested by increasing dropout and repetition rate. Demographic pressure, financial incapability, weak students’ learning interest, poor school infrastructures, poor salary structure, and incentives to keep in and attract talented teachers to the schools were identified as major challenges affecting the performance. The researchers recommend to the policy makers and educational institution leaders to design inclusive policy and financial reform of primary schools with critical implementation and monitoring to come out of these vicious circles.This study is aimed to look at the performance and challenges of public primary schools found in Bench-Sheko, Kafa, and Sheka Zones. National standards developed for Education Sector Development Program V  was used to measure the schools’ performance. Primary and secondary data are used to meet the research target. Performance reports of the schools of three consecutive years were thoroughly examined. Public primary schools found in the districts and town administration of the three zones were particularly selected for the purpose of the study. School principals, vice-principals, supervisors, district education bureau officers, and senior teachers were used as the subject of the study. Both quantitative and qualitative information was gathered and analysed. A X Ethiopia; Ethiopian schools; Gross enrolment rate; Gender parity index; Dropout rate; Repetition rate. Particularly, primary education is considered as compulsory to help the development of human personality. For this matter, almost all nations of the world structurally allocate budget, politically support, regularly supervise, evaluate and recommend its implementation. The success of these goals is monitored by core performance indicators like gross enrolment rate, gender parity index, public funding for universal education, and qualified teachers . EthiopiIt is apparently true that even today millions of children did not get access to education due to poverty, geographic location, and security. Research findings on the achievement and challenges of Education for All (EFA) have shown that since the campaign conducted on the world education forum at Dakar in 2000, many nations have increased the performance of their education system with recognizable effort. This is manifested by an increase in enrolment ratios and decreased number of students who have never been to school. Besides, Ethiopia has decreased the percentage of children out of school by remarkable rate from 67% in 2000 to 28% in 2011 . On the other hand, it is believed that financing education system and the extent of the progress of education for all is strongly linked. Primary education expenditure according to global monitoring reports of many countries has increased. Though Ethiopia has made significant progress in access to education, there is also a financial challenge faced to meet the target set in Education Sector Development Plan IV . For thiHowever, the target set was 100%. This implies that the target is not achieved. These low enrolment rate at the primary school level indicates the persistent challenges to reduce dropout and repetition. For the fact that targets set in ESDP IV were 1% for dropout and 1% for repetition, performance against these targets, however, was poor. As ESDP V begins repetition rates persist at around 8% and dropout remains at 11%. In addition, the zonal educational statistics abstract shows most primary schools in the study were operating below the expected achievement plan set in the strategy document of sustainable development goal. Bench-Sheko Zone (one of the study sites) annual statistics abstract of primary education of grade 1 up to grade 8’s average survival rate (efficiency) in 2019 was 72.15 % and was planned to reach their primary education efficiency rate at 100% though it is unrealistic. This depicts that it is suffering from primary education wastage. This particularly shows the high dropout and repetition rate recorded starting from grade 1 and became the worst at grade 8. The following Ethiopia education policy which was formulated in 2002 states that the main purpose of primary schools is to offer basic education to prepare students for further advanced education. The policy set that primary schools shall be exempted from education fees to reduce burdens from parents. It simultaneously indicated that community contribution and involvement in schooling is an important means of financing education. However, in practice, it is difficult to get a complete picture of financial contributions from the communities. As per the , the govPrimary schools’ performance is influenced by access, qualifications of teachers, leadership capacities, and representation of female leaders in leadership positions. However, the status of these determinant factors is not known in the study area. With the physical expansion of primary education, financial situation, price of inputs like education materials supplies and efforts to retain teaching staff in the teaching profession by paying good incentives need to be clearly known. For these matters, the researchers believe that the situation of primary schools’ performance needs to be studied for further intervention, clarification, and strengthening. The major factor for low education efficiency which is the major headache of primary schools needs to be examined. This study is aimed to find out the reality regarding the performance , financial strength, and challenges of the public primary schools of Bench-Sheko, Kafa, and Sheka zones of Ethiopia. These zones are found in Southern Nations, Nationalities, and People’s Region (SNNPR), South-Western part of Ethiopia. The area is well known for its numerous Ethnic groups, particularly characterized by its multicultural, multilingual, and multi-religious nature of social compositions. The original inhabitants of the area are Kafficho, Bench, Shekicho, Me’en, Suri, Zilmamo, Sheko, Dizi, and Majang peoples. Amharic and other local languages are spoken around the towns. Almost all rural communities are speaking their own native languages and very few of them speak two and more than two local languages. In terms of economic activities, forest resources, and agricultural products are major means of rural communities’ livelihood. Crops mainly coffee, fruits, and spices are the main source of income. As a matter of fact, the responsibility to provide primary education services to the communities is mainly vested in the government. A very small number of private schools (one or two schools) are found in towns of the zones and almost no private schools are found in the rural areas. Other than their limited number, their main target is to collect profit. Children from a family with good economic background have a good chance to join these schools.2This part of the paper introduces the readers to the detail of the research design employed, population of the study, sampling techniques, key methods used for data collection, nature and the sources of the data, and model used for data analysis.This study was descriptive in nature due to the intention of the study was to describe the existing situations regarding the performance of public primary schools; financial capacities and challenges found in Bench-Sheko, Kafa, and Sheka zones. The geographic location of these zones and districts is far away from the center or capital of the country. It is believed that school performance is influenced by access and qualifications of teachers, leadership capabilities, financial strength, and stakeholders’ commitment in which schools near to the center have a more comparative advantage. Though this area is known for its cash crops and spices growing, it is identified by its poor infrastructure developments. A similar situation is observed regarding primary schools found in these districts. In addition to the presence of disparities in performance by location and socio-economic situations, the researchers believed that lack of holistically designed study in the area itself justifies the need to conduct and examine this issue to scientifically identify the problems and tackle the gaps. To realize this target, the study used both primary and secondary data in order to measure the objectives set. Primary data is collected from school principals, cluster supervisors, district education officers, and teachers. The schools’ annual performance report documents are used as secondary data. Documents which was analyzed include mainly the annual educational abstract of each school organized as per their districts. Reports of primary schools organized into 22 districts and 3 administrative towns were reviewed as secondary data. Both qualitative and quantitative approaches for data collection were employed.Primary data was collected using a structured questionnaire. The survey was distributed to the schools by the enumerator through district education officers. A semi-structured interview was used for some variables. There were focus group discussions held at each district education bureau. The participants for Focus Group Discussion (FGD) was purposively selected based on their school leadership experiences and responsibilities or leadership role held in the schools. Six FGD was organized and conducted by the two researchers and one enumerator. For each FGD conducted one principal, two vice principals, one-unit leader, and four most senior staff have participated. To increase the quality of the data to be gathered through FGD, the interest of the participants and favorable situations were considered based on their consent. In addition, six different district education officers were interviewed on the overall educational achievements and challenges of schools to triangulate whether the performance report of the schools dictates the reality on the ground based on their regular supervision findings. Primary schools’ annual report documents were used as secondary data and mainly included annual educational abstracts and official reports of schools according to their district.In this study important ethical considerations were made. The researchers have protected the dignity of the respondents. Their freedom to decline participation in the study had maintained for the respondents who filled the questionnaire, attended focus group discussion and interviews. The confidentiality of the research data is safeguarded against violation of their privacy. Specifically, the respondents were communicated about the purpose of the study and freedom to fill the questionnaire in the introduction section. Accordingly, those who received the questionnaire have showed their willingness, properly filled and returned the questionnaire.Frequency distribution, mean, and chi-square test models were used according to their importance and meaningfulness. Mainly Chi-square test of independence is employed to test whether there is association between primary schools’ cycles (i.e. first cycle is from grade 1 up to grade 4 and second cycle from grade 5 up to grade 8) and changes in education access from year to year; associations between gender and school-age population of different years; gender and gross enrolment rate trends; gender and students’ dropout trends and gender and repetition rate trends across different years. Interview and Focus Group Discussion data was narrated and integrated into the quantitative data analysis by categorizing it into themes.3This portion of the paper provides the details of data analysis and presentation with specific reference to the objectives of the finding. It further discusses the results of the finding regarding primary schools’ performance, financial strength, and challenges based on both qualitative and quantitative output. In specific terms, this part dictates the result of the finding on education access, efficiency, and quality that is manifested by the nature of school-age pupils; gross enrolment rate; net intake rate; dropout and repetition rate; teacher-student ratio; gender parity index (GPI); financial strengths and challenges of primary schools used in the study.In Ethiopian education system, it is known that primary education life lasts 8 years which itself is divided into a basic education cycle covering grade 1–4 (first cycle) and a general primary cycle covering grade 5–8 (second cycle). It is critical education level to repair the education quality of the nation and basic for later education and economic growth. First cycle primary school is mainly to attain literacy, numeracy and basic awareness about oneself and ones surrounding (environment). The second cycle of primary school and first cycle of secondary school is designed to give graded general education. Primary education is followed by two years of general secondary education (grades 9–10), and two years of preparatory secondary education (grades 11–12). Senior secondary education prepares students for appropriate subjects at tertiary education including vocational and technical education to give training at different levels. Higher education is to produces career-oriented professionals in different fields of study. Education quality, access, equity, and internal efficiency are major standards emphasized as national priorities and measured by indicators. The following table indicates the number of first and second cycle public primary schools of Bench-Sheko, Kafa and Sheka Zones in 2017, 2018 and 2019 academic years.X2 - test of independence model is performed to examine the relation between the cycles and change in access to school at different years. To see whether the difference is statistically significant at each cycle, x2-test of independence with α = 0.05 is used. Accordingly, the result shows that the difference observed is not statistically significant at x2 = 0.341, df = 2, and p-value = 0.879. An increase in access to primary school implies that the government has played a major role in the expansion of primary education to meet ESDP V targets and providing overall policy guidance and monitoring of the entire sector. This is revealed by the increase in the total number of primary schools built by the government between the 2017 and 2019 academic years which was increased from 1052 schools to 1097 schools and increased government expenditure on education.At the grass-root level, it is observed that increased enrolment of students to the schools has created congestion in the classroom. Conforming with On the other hand, this scenario tells us to project the future expansion demand for secondary and higher education. In line with this, it is concluded that the relevance of lower levels of education not only to train students so that they become fit for a successful university career but also to create a sufficiently large basis of capable students from which the ablest can eventually be selected for higher education, . This shSimilarly, the researchers have observed that the expansion of primary schools seems to be at the expense of the quality of the school infrastructure and teaching-learning activities. In another word, the efforts made in order to address access to basic education target, and the physical expansion of schools did not give much emphasis to the quality of infrastructure, teachers’ qualification level, and students’ learning interests. In some primary schools  quality of the schools has deteriorated, infrastructures are limited, shortage of qualified teachers , and schools were technologically not supported.3.1Public primary school educational performance was measured mainly by gross enrolment rate and net intake rate in grade 1. Additionally, dropout rate, repetition rate, gender parity index, and ratios of qualified primary school teachers were used as performance indicators. The following X2-test of independence result indicates that there is a statistically significant relationship between gender and the school-age population at X2 = 6.65, df = 2, and p-value = 0.00). More school-age boys were found outside the school from year to year due to different factors. The main economic activities of the rural districts are cash crop growing areas particularly coffee and agricultural activities are mainly practiced. It is assumed that boys have largely engaged in these economic activities to sustain their livelihood, earn quick incomes, and subsidize their families’ expenses. According to the discussion made with the discussants, large numbers of communities live in geographically dispersed areas which creates a challenge to expand formal and basic education to ensure equitable primary education access. In spite of increased enrolment rates in some districts and insignificantly increasing at another district to meet the ESDP V goals. There was also a significant variation in enrolment of male and female students. As indicated in X2 test is calculated to examine if there was a statistically significant difference, but the result indicated that this observed difference between male and female enrolment rate is not statistically significant at x2 = 0.19, df = 2, and p-value = 0.911. Whereas according to the national education statistics annual abstract of 2017, the gross enrolment rate for primary schools was 111%. The following According to the plan, the gross enrolment rate target to be met at the end of the strategic year i.e.2020 was 103%. It is planned by assuming that it would be realized by increasing enrolment of students of the correct age for the correct grade level. However, as it is indicated in 2 = 3.08, df = 2, and p-value = 0.21. However, when it is compared with the net intake rate target which is 105 % for males and 101% for females, still some variations are observed that need to be reconsidered. For the fact that the result of the test of independence is statistically insignificant, the variation between the two sexes is decreased slightly from 18.2% in 2017 to 17.65 percentage points in 2019. The following It is understandable that the age level at which first-grade enrolment is made determines the completion rate of education. In this study official entrance age to first grade is used to know the students’ entrance age of different years in the study area by considering 100% as standard. Accordingly, 2 = 0.12, df = 2, and p-value = 0.948. It was also observed that students do not drop out once and for all rather they return back to school and join education after one or more years. The result stated that many more activities are expected to be done by the schools since the percentage of dropout rate was higher than (i.e.4.42%) the target to be met. Besides, in Ethiopia rural children are sixty times more likely to drop out than urban children . As to Though the repetition rate of students of primary schools was increasing in the years indicated, it is slightly less than the national repetition rate which was 6.8 % for females and 7.5% for males according to educational statistics annual 2 = 484.67, df = 2 and p-value = 0.00. In this case, compared with the national standard that is 1:50, the schools are performing to the standard. However, school principals have frequently raised about lack of experienced and qualified teachers which intern leads to a serious problem to handle teaching and learning activities, impacts the quality of education provided by the schools, limits education access opportunities and effectiveness of the schools. Besides, the discussants have especially justified that graduates of applied subjects were recruited to teach because experienced and qualified teachers were leaving the school. These kinds of teachers didn’t have any teaching skill training and they are not qualified teachers. The following table is the summary of the primary school gender parity index of the study area.According to the finding summarised in 2 = 120.94, df = 2, and p-value = 0.00. The fact that commendable achievements were registered by the government in addressing the quest for access to universal education and enhancing equity by increasing female education participation, still the target is not met. The effect of gender inequality in lower grades on tertiary education outcomes is more serious for disadvantaged female students than their counterparts, (Gender parity (GPI) in primary education was used to measure the realization of the target stated in education sector development program V regarding access to quality education. Accordingly, this study confirmed that though a considerable effort was made by the schools to increase female students’ enrolment to primary schools as it is described in erparts, . SimilarThe study which was presented on the global education digest in 2010 concluded that globally, girls are more likely to never enter primary school than boys. This implies that more works need to be done at the international, national, and local level to achieve and create equity and reduce disparity. The researchers believe that realizing gender parity index in school is a manifestation of educational equity and creating equal opportunities which implies addressing education development targets of the nation. Besides, in a global sense, a research report on global female education participation disclosed that female students’ enrolment in primary education was rising faster than that of males and it helped to close the gender gap at the primary level .Correspondingly, to maintain education equity it is assumed that primary schools have the responsibility to provide equal access for students with special need educations. In this regard based on the educational reports of the schools, the number of students with special need education admitted to school was increasing. However, it has been identified through observations that poor progress and practices of supporting children with special need education was in place. Special facilities supposed to be designed for this type of student are almost insignificant. School principals who have participated in focus group discussions substantiated that though their enrolment rate is increasing from year to year, challenges like lack of awareness by schools and the larger community about the academic, social, and economic support that supposed to be given for students with special need education was very less. Commitment to implement the nationally designed provisions and facilities to support them was weak. Poor school infrastructure facilities and weak pedagogical skill exposures of teachers were also identified as a challenge.3.2School principals who have participated in the interviews concluded that though public funding of primary schools is increasing from time to time, compared to the enrolment rate its ratio remains relatively low. Primary schools have faced many challenges including high enrolment rate, low gender parity index, poor learners’ achievement, lack of staff incentives, and insufficient educational materials. Funding public primary education is one of the major responsibilities of the regional government. Regional government allocates very limited budgets through zonal and district education bureaus for the schools that is used for core activities such as maintenance, purchase of equipment and furniture, and building of new classrooms. The main budget is for the salaries of teachers and administrative staff. A small budget is allocated for non-salary activities.Shortage, late approval of school budget, and irregularities of the allocated amount was a serious problem encountered by most primary schools of the study area and which apparently affects their daily planning and decision-making activities. In this case, late approval of the budget ranges for months, and sometimes it could be for a semester. Though the schools have a mandate to generate additional resources, very limited resources are generated for various reasons. Agricultural products are a source of internal income. However, a very small amount of budget is collected from agricultural products. Parents are found to be covering their students’ expenses . The insufficient budget allocated for primary schools negatively affects their performances. Additionally, budget shortage prevents the schools from paying incentives for teachers. The amount of resources collected from the community for different means varies due to different economic or earning capabilities of the community to contribute to the schools. This was peculiar to particularly rural schools that have weak economic potential and which suffer from insufficient budgets to implement their plans. The budget shortage is particularly challenging in rural schools where community contributions are small and students are exempted from paying school fees.Mismanagement of school resources like farmland, crops, trees, and grasses was also reported as a problem. A school board and Parent Teacher Association (PTA) is responsible for the management, organization, and administration of the school budget in general. Not only budget shortage but also a decision for utilization is with full of challenges and time taking. School principals have no autonomy to decide on the budget and use it when the need arises. For instance, if the school want to buy accessories for daily activities like photocopy machine and computers, it is a must to request the school board or parent-teacher association’s consent.3.3The discussants repeatedly said that primary schools have a problem with students’ learning motivation which was demonstrated by high dropout, high repetition rates, and low teachers’ teaching commitment. The schools have a shortage of experienced qualified teachers, a limited number of classrooms and sanitary facilities, and low support given to children with disabilities. However, gross enrolment rates were increasing from year to year relative to the performance of the school recorded during ESDP IV. According to the discussant’s explanation, though there was no culture of regularly rating student learning interest both at national as well as at regional education bureaus, the present practice and observation indicate that students’ learning interest is poor. These are manifested by the situation in which significant number of students are not motivated to actively engage in learning activities and take responsibility for their academic records. After they graduate from primary school a significant number of students show difficulty with numeracy and literacy skills. The schools’ yearly performance report attributes these problems to the socio-economic background of students’ parents and the nature of the economic activities of the environment that attracts the attention of the students more than the school. The discussants from the schools also affirmed that weak schools’ budget utilization and less support from the community in planning, decision-making, and resource mobilization were mentioned as major challenges influencing their performances.Additionally, it is explained that the present earning salary and incentive practice of primary school teachers is very poor and does not sufficiently cover their basic expenses which in turn resulted in a lack of commitment to teaching, supporting students and even leads to high teachers’ turnover year in year out. This by itself caused qualified and experienced teachers to even leave schools very shortly and their engagement in professional development activities was also weak or not at all. In this regard, the respondents in group discussion expressed their opinion by saying a systemic, integrated, and transparent performance evaluation mechanism of primary school teachers and associated benefits are still missing which leads to less commitment to engage in continuous professional development activities.4It is found that the schools were progressing in access. However, much more work is expected to be done by the School Leaders, Non-Governmental Organizations (NGOs), Partners, Parents, Local, Regional and National Governments to meet the nationally expected targets of access to primary education without compromising its quality. Enrolment rate was increasing with the existing infrastructural facilities. This situation was creating burdens on the school leadership, teachers teaching load and effectiveness, and students learning interests. Qualified experienced teachers are leaving the schools and joining different careers to get extra income in order to subsidize their living costs. These problems lead the school in order not to progress in line with the expectations and affect the quality of teaching-learning activities. The researchers recommend that to significantly reduce this problem intervention is needed at the policy level which may include making inclusive policy reform, critical implementation, monitoring, and evaluation regarding standardizing the number of students that each school should enrol, quality and quantities of teachers needed, minimum school facilities required, standardized and diversified funding system and the overall teaching and learning packages of primary schools. Creating shared responsibility among the school leadership, local administrators and the community is a key to systematically avert problems and enhancing educational efficiency by reducing dropout and repetition rates.Miressa Yadessa: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Wrote the paper.Matheas Shemelis: Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Mizan-Tepi University.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This work was supported by Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.