The Integrated School Health Policy is being implemented in public schools as the integrated School Health Programme (ISHP). The programme’s implementation supports South Africa’s commitment to “Put Children First”, as a signatory to the Convention on the Rights of the Child.

In addition, in 2010 President Jacob Zuma committed to reinstating school health programmes in order to address the imbalances that contribute to unequal health outcomes for school children. Both the Departments of Health (DOH) and Basic Education (DBE) are signatories to the Integrated School Health Policy.

Context

Health problems of schoolchildren

The ISHP highlights health problems in schoolchildren such as hearing and vision impairment, poor oral health, HIV and AIDS, mental health issues such as psychiatric disorders, and risky behaviours including substance abuse and unsafe sexual practices.

Social determinants of health

The programme identifies the many social determinants that negatively affect the health and development of children. Among these are socio-economic issues
such as poverty, orphaned children, child-headed households. The ISP also considers food insecurity and malnutrition, including under- and over-nutrition with their consequences such as stunting and obesity.

An additional social determinant of health is the physical environment in which children live and study. The ISHP raises the issue of inadequate water and sanitation in homes and schools. Even in homes where there is an electricity supply, some cannot afford to use it. Many people try other energy sources such as [kerosene or open fires] which pose health risks.

The ISHP, however, maintains that there are plans to address backlogs in the provision of water, sanitation, electricity and fencing in schools. The mention of school fencing implies that the safety of children is at risk in educational institutions. Young people are also identified by the ISHP as being exposed to high levels of trauma and violence, including sexual assault.

Implementation of the ISHP

The programme emphasises two new developments – one each from the health and education sectors – for its implementation. Both require intersectoral and interdisciplinary actions.

Firstly, the programme emphasises the Primary Health Care (PHC) approach. PHC has four key components: curative, preventive, promotive and rehabilitative. Together, these ensure comprehensive health care and actions that can address the social determinants of health.

Secondly, the ISHP identifies the DBE’s Care and Support for Teaching and Learning (CSTL) framework as central to its implementation. The provision of school health services is a key component of this framework. It aims to realise the educational rights of all children by turning schools into inclusive centres of learning, care and support.

This eco-systemic approach includes nine priority areas: nutrition, health promotion, infrastructure including water and sanitation, social welfare services, safety and protection, psychological support, curriculum support, cross-curricular support, and material support.

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SUMMARY OF ISHP

Vision

The optimal health and development of schoolchildren and the communities in which they live and learn.

Goal

To improve the general health of school-age children as well as environmental conditions in schools and to address health barriers to learning.
Specific objectives

To provide preventive and promotive services in response to the health needs of schoolchildren and youth, for both their immediate and future well-being.

To support and facilitate learning by identifying and addressing health barriers to learning.

To facilitate access to health and other services where required.

To support the school community in creating a safe and secure environment for teaching and learning.

Key strategies

1. Health education and promotion

Health education will take place mainly through the Life Orientation curriculum, supplemented by cross-curricular activities. It will teach students about: nutrition, exercise, personal and environmental hygiene, chronic illnesses (including HIV and TB), abuse (sexual, physical and emotional abuse, including bullying and violence), sexual and reproductive health, HIV counselling and testing, male circumcision, and mental health issues such as drug and substance abuse and suicide.

2. Provision of an essential package of health services in schools

Learner assessment and screening

Students will be assessed for vision, speech, hearing, movement, oral health, nutritional status, weight, height, chronic illness, anaemia, mental health and psychosocial risk.

On-site services

On-site services will include de-worming, immunisation and the treatment of minor ailments. Sexual and reproductive health information and related services will also be available. In addition, the ISHP encompasses environmental assessment by qualified officers and the provision of adequate water and sanitation, physical safety and first aid kits. Services will also address issues of food safety and suitability. The programme suggests that some on-site services could be provided by NGOs on a voluntary basis.

Follow-up and referral

Mechanisms must be in place to ensure that identified learners obtain any services that cannot be provided on site through routine school health provision. Therefore the use of mobile health units is also recommended where available. The Department of Social Development (DSD) will be responsible for assisting students to gain access to such services. This will include helping learners to secure financial support for transport to and from health facilities.

3. Coordination and Partnership

The policy acknowledges international evidence showing that successful school health programmes depend on strong partnerships between:

• Education and health sectors
• Teachers and health workers
• Schools and community groups
• Students and people responsible for school health programmes

Government and trade unions, the private sector, academic institutions, and NGOs.
The ISHP recognises that the National and Provincial DoH, DBE and DSD must together oversee collaboration between all parties taking part in the programme. It also suggests that students should be involved in the implementation of health policy in their schools and communities.

4. Capacity Building

Training at all levels of the DBE and DoH will be required for those involved with school health.

5. Community Participation

The ISHP states that community mobilisation is important “to create awareness for people to take positive action towards improving [the] health of learners in schools”. It emphasises active community involvement to secure buy-in from school governing bodies, community leaders (traditional/faith-based/ward councillors) and the entire school community (students, teachers, parents).

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Critical appraisal of the policy

The ISHP acknowledges the many factors that affect the health and overall development of school-age children. However, despite a comprehensive PHC approach and the CSTL framework, there is a strong focus on service delivery to address pre-determined issues, with little acknowledgement of the other needs of the school community. While the ISHP acknowledges the importance of intersectoral intervention, the package of proposed services will not fully address the social determinants of health.

The emphasis on health education throughout the school curriculum focuses on individual behaviour change. This approach does not address the wider social determinants of health. In fact, the ISHP has very little emphasis on health promotion beyond health education. South Africa needs to support people to take better control of their health by creating environments in which adequate water, sanitation and food security are facilitated by government.

The health-promoting school (HPS) approach of the ISHP incorporates elements of CSTL and thereby addresses many factors affecting health. HPS is underpinned by the Ottawa Charter with its action areas of community participation, reorientation of services, development of personal skills, creation of supportive environments and development of policies for good health. Enablement, advocacy and mediation are the three principles of health promotion that the Charter applies to these action areas.

Forging links

A good example of this intersectoral action is the DoH’s deworming programme that was used to launch HPS in Khayelitsha schools. This programme required links between the Departments of Health, Education, and Public Works.

School nurses introduced staff at Sakumlandela Primary School to HPS through the deworming programme, which entails teachers administering tablets to students on a six-monthly basis (Reorientation of services).

The programme was broadened to include teaching students about how to prevent worm infestations (Skills). It expanded further to include cooperation with the Department of Public Works to improve sanitation at Sakumlandela Primary (Environment), and links with a community forum to upgrade sanitation in the surrounding area (Community).

The needs of school communities for services other than those forming part of the ISHP package should also be considered. Indeed, one of the ISHP’s implementation principles is that it must focus on the rights of children. But apart from consulting learners to support its implementation there is no other indication as to how children could be actively involved. However, their voices need to be heard on issues affecting their own health.

For example, the charity Save the Children uses children’s committees to give youngsters a platform. The purpose is not only to encourage child participation but also to allow them to act as agents for change. This establishes a mechanism which is always active, connecting children, their community and teachers as well as other adults who have the capacity to carry out duties at a municipal level.

Young advocates

Thus whenever a problem arises in the community – for example, an outbreak of measles, or a breakdown of services affecting children – children’s committees are in a position to contact the relevant person and advocate for a solution. A case in point occurred when a children’s committee lobbied their local municipality to build a new bridge which would enable school attendance during the rainy season.

This type of social mobilisation and community participation are key to the implementation of the ISHP. Health workers will be so busy delivering clinical services at schools that they will not have time see to the other needs of the school community. They may not even have much contact with the community.

Another reason why social mobilisation is key to the realisation of child rights, is that it encourages health-seeking behaviour by parents, children and teenagers. This helps to move people away from a culture of believing that all responsibility for child services rests with the school.

By mobilising families to develop attitudes of responsible citizenship and to participate in decision-making or holding clinics to account, we can help them to become active in ensuring good service delivery. This will prevent people from being passive recipients dependent on the goodwill or unpredictable quality of any services that happen to be available.

The ISHP proposes the use of community health workers (CHWs) for some service delivery in schools. However, they could play a bigger role in the ISHP by becoming a link between communities and schools, and advocating for the needs of the school community. They could also be the link to NGOs and other institutions in the area that may address some of the needs of the school.

CHWs would, however, need to be equipped to play such a role. If outside bodies are allowed to work in schools as the ISHP suggests, formal guidelines will be required. These will need to be developed in collaboration with such bodies. The DBE will also have to ensure that they are given access to schools in order to address the needs of the school community.

Shortage of resources

Crucially, the implementation of the ISHP will require major financial and human resources. At present the number of school nurses is woefully inadequate. The same is true for environmental health workers. Moreover, will the different sectors cooperate to fulfill the ISHP requirements, especially if they lack the capacity to implement their own sectoral policies?

A further concern is how schools and PHC facilities which have their own priorities will manage the extra workload and human resources required to support school health. The ISHP proposes training for those involved in school health. However there is no reference to what such training will entail.

It is important that those charged with implementing the ISHP have the capacity to do so. If we are to adequately address the social determinants of health, staff will need training in community development. However at the moment nurses are only trained to provide clinical services. Will a nurse heading up a school health team have the capacity to consider the wider needs of the school community? Will CHWs and health promoters have the capacity to look at health promotion in its broader, environmental sense?

Training those involved in school health needs careful planning to acknowledge the different roles and responsibilities of various sectors and levels of government. The ISHP also needs clarification on the training, registration and roles of health promoters and CHWs in school health programmes. It is important that staff from different sectors are trained together so that everybody understands each other’s responsibilities in the ISHP.

Finally, the ISHP’s monitoring and evaluation plan does not include assessing the process of implementation. It is vital to focus not only on outcomes but also on the process itself. For example, monitoring collaboration between sectors is essential because interdepartmental collaboration is a key strategy of the ISHP. There should also be indicators to evaluate whether the programme is implemented in line with the PHC approach and the CSTL framework.

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Conclusion

In summary, the ISHP has promise. At face value, it seems to address the key social determinants of health. However, as it stands it runs the risk of providing a package focused on service delivery but offering limited health promotion.

Although guidelines are available for implementing the ISHP, there is clearly an urgent need to review its emphasis and to allocate sufficient, suitable resources. So far the human resources development plan is unclear. It is questionable whether school health personnel, apart from delivering services, will have the capacity to change students’ environments, making them healthier and more conducive to learning.

The ISHP needs an eco-systemic approach to tackle the many factors affecting the health and development of schoolchildren. HPSs have already been established in all nine provinces in South Africa, with most of this development taking place in disadvantaged communities. We propose that the ISHP should build on what already exists by employing the HPS approach to improve both health and educational outcomes.

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Views expressed in this article are those of the authors and do not necessarily reflect the views of SECTION27 and the Treatment Action Campaign

Suraya Mohamed, Trish Struthers and David Sanders are all of the School of Public Health, University of the Western Cape. Sanders is a member of the Steering Committee of People’s Health Movement, South Africa. The authors gratefully acknowledge the assistance of Melinda van Zyl of Save the Children, South Africa.