The ISHP in the Western Cape
The Integrated School Health Programme has the potential to prevent many pregnancies and HIV infections. But, to judge by its introduction in the Western Cape, it will take serious political will to make access to condoms and HIV testing a reality for students.
The Western Cape launch
18 February 2013 marked the launch of a National Health Insurance (NHI) pilot project in the Western Cape’s Eden district. The project is to be conducted under the umbrella of the Integrated School Health Programme (ISHP).
The ISHP will promote health and preventive care among schoolgoers, in addition to providing curative and rehabilitative services. Among the health screening services on offer will be assessments of height and weight, oral health, skin health, vision, hearing, and speech. In addition, students will be assessed for mental health and psychosocial support. All learners are to be immunised, and older students will also benefit from counselling on sexual and reproductive health.
The pilot is the start of a collaborative effort between the Western Cape’s Departments of Health and Education. Eventually the ISHP will be implemented in all health districts of the Western Cape.
However, staffing models used to implement the programme will vary across the province. The Cape Metropole and Eden districts have dedicated school health nurses to provide care. In other, rural districts, the programme will be implemented as an outreach activity by the primary care facility located nearest to the relevant schools.
The ISHP will be phased in over a five-year period, commencing in 2013.
How will it work?
Discussion of HIV and teen pregnancy will be covered in schools as part of the Life Orientation section of the ISHP. From Grade 8 onwards health screening services will check for STIs and chronic conditions such as HIV and TB. Any information, counselling or testing that is not available on site will be conducted at the nearest health care facility.
The ISHP also allows for the provision of condoms in schools as part of the health education component of the programme. However, the latest draft of the ISHP resource manual for school nurses permits the distribution of condoms to students on site only with the approval of school governing bodies.
The ability of governing bodies to block the distribution of condoms or the provision of HIV testing within schools is regrettable. It is a lost opportunity to prevent HIV infections and pregnancies among adolescents.
Although school nurses can refer students for HIV testing at the nearest health facility, there is a risk that students will fall through the cracks unless there is a suitable follow-up mechanism. Such follow-up should ensure that learners are received by a health facility and obtain HIV counselling and testing (HCT).
When asked about the rollout of the ISHP in the Western Cape and the provision of contraception and HIV testing services in school, the Western Cape Department of Health noted:
“As the Western Cape’s Integrated School Health Programme is a collaborative effort between the Departments of Health and Education, the Western Cape respects the boundaries set by the Department of Education on the package of health care service delivery in schools.”
An important ruling
Certain provisions of The Sexual Offences Act criminalise consensual sexual behaviour between children aged 12 to 16 years. However, a recent High Court ruling (see page 4) declared these provisions to be unconstitutional. This has been welcomed by many who saw the Act as a barrier to young people obtaining the health advice and support that they need.
Guidance from teachers, nurses and social workers represents a critical opportunity to promote safe sexual practices among young South Africans. The High Court ruling now allows young people to seek advice on contraception and safe sex without fear of prosecution.
One of the main focus areas of TAC’s work in Khayelitsha in 2013 will be the provision of condoms in schools. Having distributed over ten million condoms in the local community in recent years, the logical transition for the organisation is to begin focusing on schools, says Booysen.
“There is a real gap in the provision of condoms to our youth, and schools [are] a good [means] to bridge it. Condoms have proven very effective in curbing the HIV epidemic in our community,” she notes. “[We] need … political will and leadership to address HIV prevention and teen pregnancy in schools.”
The Masiphumelela Youth Centre
The Desmond Tutu Foundation’s Youth Centre in Masiphumelela, Cape Town, right across from the local high school, takes a holistic view of HIV programmes. The centre not only provides health services such as HIV testing and family planning, but incorporates a strong educational and leisure component.
Young people at the centre have their own advisory board, known as the Future Fighters. This allows them to take ownership of their health and to play an active role in developing services that cater to their needs.
The foundation was recently approached to participate in a project called Prepare, which is led by the Medical Research Council (MRC). Prepare aims to reduce the incidence of HIV among school students by promoting sexual and reproductive health.
To support the project the foundation was asked to provide a nurse in local schools. Prepare’s intention was to make contraceptives and HIV testing services available to Grade 8 students. Unfortunately the Department of Education has decided to exclude those services from the intervention package.
One of the schools to benefit from the intervention package will be Masiphumelela High School. Prepare will adjust its plan for the high school to accommodate the reservations of the Department of Education. It will encourage students to walk across to the Masiphumelela Youth Centre where they can obtain family planning support and HIV testing. The nurse will be present on the grounds of the centre instead of the school. But other schools and their students may not be as fortunate in having access to an alternative facility.
When asked to describe their major concerns about HIV testing – whether on school grounds or elsewhere – learners like those in Masiphumelela often express worries about confidentiality. Such concerns cannot be ignored. One solution would be to use nurses or counsellors who are not from the community where testing takes place.
Programmes like Prepare and the ISHP must take these concerns into account. In the meantime, a major advantage of these projects is that sexual or reproductive health services can become ‘normalised’ when they are provided within a package of broader health care. When these services are perceived as part of routine health support, young people are more likely to take them up.
The ISHP is a unique opportunity to bring health services closer to school students. It has the potential for a significant impact on the burden of disease and pregnancy that plagues South Africa’s youth. We cannot afford not to make it work.
Western Cape DoH press statement http://www.westerncape.gov.za/news/nhi-pilot-project-launched-eden-district
By Donela Besada