Swedish school law stipulates that the work of student health teams in schools should be mainly health promoting. However, earlier scientific studies and reports from authorities show that most schools work aren’t. The aim of this study is to investigate how principals in five upper secondary schools organize and lead the health promoting work and what challenges they experience in their leadership with regards to health promoting work. The study is qualitative, based on a content analysis of semi-structured interviews with five upper secondary principals in Sweden. The results of the study show that even though the principals have access to interprofessional health teams and good organizational structures the student health work in four out of five schools mainly focus on remedial work and that more must be done in order develop their health promoting work. More focus must be appointed to developing teaching and teachers and student health team personnel must work closely together. In addition, principals must integrate their health promoting work in the systematic quality work of the school.