Mrs Angie Motshekga, MP
Minister of Basic Education
During his keynote address at the launch of the Integrated School Health Programme (ISHP) in October 2012, the President Jacob Zuma labeled the ‘bringing back of school health services’ a revolution for South Africa. Positioned at the nexus of government’s apex priorities namely, improving the quality of basic education (Outcome 1: Basic Education) and providing a long and healthy life for all (Outcome 2: Health); the ISHP is strategically positioned to give impetus to both outcomes. Implemented in partnership by the Departments of Basic Education, Health and Social Development, the ISHP demonstrates what is possible when government departments work together towards a common vision.
The inextricable link between health and education is well documented. Education is well recognized as a key determinant of a range of health outcomes. Equally so, failure to address key health barriers to learning, such as problems with vision, hearing and speech have been shown to impact negatively on educational outcomes.
South Africa has a long history of providing school health services that pre-dates the advent of democracy. However, service provision has been fragmented, variable and sub-optimal. Through the Department of Basic Education’s Care and Support for Teaching and Learning (CSTL) Programme, the provision of school health services is receiving priority. The CSTL Programme aims to turn schools into inclusive centres of learning, care and support. The focus on school health services has found resonance in the initiative of the Department of Health to re-engineer primary healthcare, and to strengthen health promotion and prevention efforts.
The Integrated School Health Programme (ISHP) is designed to scale up school health services to reach all learners in the schooling system (approximately 12 million) over the next five years. The Programme builds on the successful collaboration of the Departments of Basic Education and Health since 2010 that has reached approximately 1 174 810 learners through bi-annual School Health Weeks and other means.
The Department has also purchased 1 897 scales, 2 025 stadiometres and 12 659 Snellen’s charts that have been invaluable in ensuring service provision.
While some may label the intention to reach all learners over the next 5 years ambitious, the rationale for extending services is substantive when reviewed against the backdrop of the burden of disease amongst children and adolescents. Behaviours and health challenges in this age-group not only inevitably impact negatively on teaching and learning; they have the potential to generate a whole host of risk factors (such as smoking, drinking and unhealthy dietary habits) that result in preventable disease and death in adulthood (such as cardiovascular disease, diabetes and cancer).
The 2008 Youth Risk Behaviour Survey (YRBS) conducted among Grade 8-11 learners showed that while 13% of learners are stunted (low height for age) and 4% have wasting (low weight for height), 20% of our learners are overweight and 5% can be classified as obese. Worryingly, 21% and 35% percentage of learners are smoking and drinking on a monthly basis, and 29% binge drink (for girls drinking 3 or more drinks in one sitting, for boys drinking 5 or more drinks in one sitting).
The ISHP will offer a comprehensive and integrated package of health services in an age and developmentally appropriate manner aligned to the four educational phases (foundation, intermediate, senior and Further Education and Training phases). During its inception years, it will target our most disadvantaged learners (no fee paying schools) in primary and secondary schools, as these children are the least likely to access health services in their private capacity. Learners repeating grades will also be prioritised. Over time, the programme will be extended to all learners.
As necessitated by the need to improve general health literacy and to prevent ill-health among all South Africans, the ISHP will prioritise health promotion activities. The health services package will therefore include the following: Health education that is aligned to the curriculum so as to re-enforce what is covered in the classroom. Topics include lifestyle choices for a healthy life and alcohol and drug abuse; Health screening for vision, hearing, oral health and Tuberculosis. Screening will also be conducted for psychosocial well-being; and Onsite services for minor ailments, deworming as well as catch-up immunization.
Services will be provided by school health teams led by a Professional Nurse linked to primary health care facilities. In addition to the lead nurse, each team will include a nursing assistant or an enrolled nurse, an oral hygienist and a Health Promoter. The inclusion of an oral hygienist in the team is based on the evidence collected during the screening of Grade 1 learners, that inordinate numbers of learners are referred for oral health problems.
The ISHP is however not without controversy. While there is universal agreement that screening children for their vision, hearing and oral health is the right thing to do, the provision of sexual and reproductive health services to our older children is contested.
In 2008, the YRBS reported that 37% of Grade 8-11 learners were sexually active. According to the School Annual Survey, in 2010, 36 702 pregnant adolescents attended school.
There is universal acknowledgement that young people are both the drivers of the turn-around strategy for HIV. They are the drivers because 40-50% of new infections occur amongst young people (ages 15-24); and they are the turn-around strategy because the first downturns in the epidemic that we have experienced have been amongst this age group and are attributed to changes in their behaviour.
Bearing this evidence in mind, and that the sexuality of young people will always be a contested issue in society, education stakeholders together with the Departments of Basic Education and Health agreed that the parent body of every school will be consulted to consider the merits of the provision of sexual and reproductive health services to learners, before such services are offered.
Sexual and reproductive health (SRH) services for learners extend well beyond the provision of condoms in schools. A comprehensive approach has been adopted that encompasses health education and counseling including on pregnancy and Male Medical Circumcision, together with an offer of contraception and provision of condoms; screening for Sexually Transmitted Infections (STIs); pregnancy testing; and HIV Counselling and Testing (HCT). SRH services will be provided by a professional nurse only, in a private one-on-one consultation. Where facilities are not available in schools to protect the privacy of learners, learners will be referred to health facilities for services.
The programme is governed by a strong ethics framework. Participation in the ISHP is voluntary, although the public health benefit is substantive. Parents and learners also have the right to participate in some or all of the health services on offer. Keeping in mind that both learners and parents are the key constituents of the education system, active parental consent will be sought. This decision is not only based on legal requirements, but on growing evidence that children seek the support of their parents first when faced with health and social challenges. In accordance with the Children’s Act, learners who are 12 years and older must provide their assent to participate in the programme. Where children assert their right to access services independent of their parents, they will be counseled on the importance of adult support, and services will be provided.
Building sufficient numbers of school health teams with adequate physical resources to extend services to over 24 000 schools is a mammoth undertaking. But the country is not without options or resources. Organisations such as Catholic Institute of Education, Colgate Palmolive, loveLife, Phelophepa Health Care Train and Soul City have offered invaluable services to schools, some dating back over 30 years. Universities, colleges and technical colleges also utilize schools for experiential learning for students simultaneously extending valuable services. Consolidating the resources, technical skills and goodwill of all stakeholders and partners will assist in extending the reach of school health services.
The success of the ISHP hinges on the integration of service provision amongst health, basic education, social development and key private, non-governmental and development partners. But the provision of services by the state must been matched, in equal proportion, by the demand for services by school communities. Active community participation in the programme will ensure the provision of high quality services within an ethical framework that is accessible and acceptable to the school community.
Revolutions happen when a wave of momentum is created in communities through open dialogue and communication. We ask you as parents and members of the public to give this revolution momentum by raising awareness about the importance of the ISHP; offering your help to the principal to assist the school health team on the day of service provision; signing and returning the consent form to the school, giving permission for your child to receive services; explaining to your child what will happen on the day and put them at ease; sending your child’s original Road to Health Card to the school (if your child is 14 years and younger), so that the team can ensure that he/she receives the correct immunization and it is recorded; accompanying your child, where possible, on the day of the screening to provide his/her medical history; taking your child to the clinic or hospital for further assessment and treatment when referred; and informing the school of the outcome of further assessment and treatment received at the clinic or hospital.
The welfare of our children is in our hands; everybody must take active interest and play their part.