Comment 2418 www.thelancet.com Vol 392 December 8, 2018 Access to afordable, quality-assured essential med- icines is a prerequisite for efective universal health coverage. 1,2 Eforts to ensure comprehensive access to essential medicines have been hindered by a dearth of information. Most monitoring eforts have focused on measurement of a prespecifed list of essential medicines in health facilities. Measures of afordability in private and public health facilities have relied on periodic surveys, usually by non-governmental organisations (NGOs) or academia. 3 The quality of medicine products A global accountability mechanism for access to essential medicines layperson could be more infuential and less threatening in changing students’ and teachers’ practices. This option raises implications for resourcing. With schools increasingly employing nurses, social workers, and school counsellors, is there potential to employ youth workers, health promoters, or cultural support workers to enhance school wellbeing? Could these non-teaching staf lose their ability to challenge the status quo in schools if they become internal employees with teachers as their managers? Careful negotiation of these roles and management will be needed to ensure the legitimacy of their roles as part of the school environment while maintaining their independence and ability to challenge. Third, there are several aspects that require further development and evaluation. For example, can the programme be enhanced to improve areas that were relatively resistant to change—eg, aggressive behaviours and perpetration of bullying in the INCLUSIVE trial? What might explain the diferent efects by gender in these trials, and to what extent might intervention efects vary by age, ethnicity, religion, or other diferences? Finally, some school health promotion messages can appear incongruous, and be less efective, in the context of wider societal norms. About 720 million school-aged children live in countries where corporal punishment at school is not fully prohibited. 3 Although they found favourable efects on drinking, the investigators of the INCLUSIVE trial suggest that the lack of efect on sexual health could be due to these behaviours typically occurring outside school. The difculties in improving sexual health might lie in social taboos and cultural norms that prevent open and honest discussions with adolescents about relationships, consent, and safer sexual behaviour without resorting to shaming or use of scare tactics. Notwithstanding issues that require further attention, both trials provide compelling evidence to target investments and resources to enhance school environments as a social determinant of health amenable to modifcation. *Shanthi Ameratunga, Terryann Clark, Prerna Banati School of Population Health, Faculty of Medical & Health Sciences (SA), and School of Nursing (TC), University of Auckland, Auckland 1142, New Zealand; Manaia Primary Health Organization, Whāngarei, New Zealand (TC); UNICEF Ofce of Research – Innocenti, Florence, Italy (PB) s.ameratunga@auckland.ac.nz We declare no competing interests. Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. 1 UNESCO. Global Education Monitoring Report 2017/2018 - Accountability in Education: Meeting our Commitments. Pars: United Nations Educational, Scientifc and Cultural Organization, 2017. 2 World Bank. Secondary school enrolment – data from the UNESCO Institute for Statistics. 2018. https://data.worldbank.org/indicator/SE.SEC. ENRR?view=chart (accessed Aug 20, 2018). 3 UNICEF. An Everyday Lesson: #ENDviolence in Schools. New York: Division of Communication, Programme Division/ Child Protection and Education, 2018. 4 Menesini E, Salmivalli C. Bullying in schools: the state of knowledge and interventions. Psychol Health Med 2017; 22 (suppl 1): 240–53. 5 Leschied AW, Saklofske DH, Flett GL, eds. Handbook of School-based Mental Health Promotion: An Evidence-informed Framework for Implementation. Cham, Switzerland: Springer, 2018. 6 Aldridge JM, McChesney K. The relationships between school climate and adolescent mental health and wellbeing: A systematic review. Intl J Edu Res 2018; 88: 121–45. 7 Milfont TL, Denny SJ. Everyday environments and quality of life: positive school and neighborhood environments infuence the health and well-being of adolescents. In: Fleury-Bahi G, Pol E, Navarro O, eds. Handbook of Environmental psychology and quality of life research. Switzerland: Springer International Publishing, 2017: 369–84. 8 Shinde S, Weiss HA, Varghese B, et al. Promoting school climate and health outcomes with the SEHER multi-component secondary school intervention in Bihar, India: a cluster-randomised controlled trial. Lancet 2018; published online Nov 22. http://dx.doi.org/10.1016/S0140- 6736(18)31615-5. 9 Bonell C, Allen E, Warren E, et al. Efects of the Learning Together intervention on bullying and aggression in English secondary schools (INCLUSIVE): a cluster randomised controlled trial. Lancet 2018; published online Nov 22. http://dx.doi.org/10.1016/S0140-6736(18)31782-3. 10 Ebersohn L. Making sense of place in school-based intervention research. Contemp Edu Psychol 2015; 40: 121–30.