A situational analysis for the implementation of the National School Health Policy in KwaZulu-Natal

Abstract

The South African National School Health Policy was launched in 2003 to improve pupils' health by linking school visits by nurses and other health providers with the intersectoral collaboration required for health promoting schools. In KwaZulu-Natal, the policy required that various parties collaborate in order to ensure the successful implementation of the policy. This study examines the status of provincial departments and district level groups and their capacity to contribute to this partnership. It is a situational analysis that includes interviews, a questionnaire and focus group discussions. The results reveal issues that need addressing before the policy can be successfully implemented, including staffing, transport for the School Health Teams and further training of these teams and the teachers. Given the health issues faced by South Africans, especially the quadruple burden of disease, it is imperative that the School Health Policy be comprehensively implemented in KwaZulu-Natal.

Keywords:

• school health policy
• health promoting schools
• KwaZulu-Natal

1. Introduction

The National School Health Policy (SHP) was launched in July 2003 to address the historically poor school health delivery prior to and immediately after the 1994 watershed elections which saw the demise of apartheid and birth of true democracy in South Africa. The South African Department of Health (DoH) was obliged to formulate and implement a school health programme under both the United Nations Convention on the Rights of the Child and the South African Bill of Rights. The National SHP was intended to redress the inequities of the past and improve health service delivery to schools. It is designed to complement policies such as the Integrated Nutrition Programme, which has established a school feeding programme in disadvantaged schools, and the social grants for children that the government provides (DoH, 2002). The National Food Consumption Survey, conducted in 1999, found that 8% of children in South Africa were stunted and 1% severely underweight (DoH, 2002). Since then the HIV/AIDS/TB epidemic has resulted in increased morbidity and mortality and KwaZulu-Natal is the province with the highest prevalence of HIV infection (DoH, 2009). The high level of unemployment in KwaZulu-Natal, unofficially estimated at 40% (Kingdon & Knight, 2006), further exacerbates the health problems of disadvantaged communities, in respect of both nutrition and accessing health care. Effective implementation of the SHP could therefore help promote health in such communities.

With over 25% of the South African population being in school at any given time, the school is an effective forum for improving the health of the population through education, particularly of pupils, school personnel, families and members of the community. This is especially important in South Africa because of the quadruple burden of disease, with a high percentage of deaths caused by communicable diseases, non-communicable diseases, injury and HIV/AIDS. Whereas in the West injury and HIV/AIDS account only for low percentages of premature mortality, in South Africa more than half the premature deaths in 2000 were as a result of injury and HIV/AIDS (Bradshaw et al., 2003). Health education in schools can be used to address this problem urgently by devising educational programmes aimed at reducing these mostly preventable causes of death. Referring to this opportunity for health education, the then Minister of Health said: ‘Logic dictates, therefore, that we do all in our power to ensure that this very vital section of our population gets introduced to sound health practices’ (Tshabalala-Msimang, 2003).

The National SHP was implemented after South Africa became one of many countries worldwide to introduce the ‘Health Promoting Schools’ concept. This idea had its roots in the World Health Organization's Ottawa Charter for Health Promotion (WHO, 1986). The principles of the Charter were applied to the school context, resulting in this concept which aimed ‘to improve the health status of children and to improve the development of quality education’ (Mukoma & Flisher, 2004). Successful implementation of this concept was intended to help achieve healthy lifestyles for the school population by developing supportive environments conducive to the promotion of health (Cliff & Jensen, 2005). This required a collaborative approach by several role players from various government departments, particularly the DoH, Department of Education (DoE), and Department of Social Development. Over 1000 such schools were established in South Africa during 2006/07, with 154 being in KwaZulu-Natal. Swart & Reddy (1999) pointed out the challenge for the different role players to work synergistically in order to get the network of Health Promoting Schools off the ground in South Africa: to improve the health of disadvantaged communities, where socioeconomic conditions are poor, requires an intersectoral approach and considerable human and material resources. The SHP would in many ways have to be integrated with this network, and similar challenges would be faced.

KwaZulu-Natal is the South African province with the largest number of pupils (2.5 million) in over 4000 schools (DoH, 2007). It is also one of the poorer provinces, with an estimated 60% of the population living in rural areas, historically the most disadvantaged (DoH, 2007). Many of the schools servicing this population are situated in distant areas of the province, which are often difficult to reach because of poor infrastructure (James & Moodley, 2006).

At the provincial level, the KwaZulu-Natal DoH, through the directorate of Maternal, Child and Women's Health, planned to implement School Health Services, based on the KwaZulu-Natal SHP and Implementation Guidelines (DoH, 2007). These guidelines were drafted for the province in line with the National SHP and aimed to develop comprehensive and integrated School Health Service within the framework of Primary Health Care, the District Health System, and Health Promoting Schools. The SA Yearbook for 2008/09 states that:

The aim of the National School Health Policy (passed in 2003) and Guidelines was to ensure that all children, irrespective of race, colour and location, have equal access to school health services. The nurses will be trained to:

•	provide children with health education,
•	impart life skills,
•	screen children, especially those in Grade R1 and Grade 1, for specific health problems, and at the puberty stage when children undergo physiological changes,
•	detect disabilities at an early age, and
•	identify missed opportunities for immunisation and other interventions. (Burger, 2009)

Available resources were to be used optimally so as to remove the health barriers to learning and provide effective preventive, promotive, curative and rehabilitative services within the Primary Health Care framework. This would be achieved by equipping health workers, teachers and other role players with the necessary skills. In terms of the Policy, these services aimed to develop partnerships created by schools, other service providers and communities to provide a health service that would promote the health and educational development of school-aged children and adolescents. Collaboration between the School Health Team and other service providers in the school and community was required to achieve this, and the KwaZulu-Natal SHP and Implementation Guidelines provided the necessary framework.

The SHP identified the roles of the National and Provincial Department of Health in the implementation. At National level these included consultations with the DoE to ensure

•	collaboration and integration,
•	finalisation of the Health Promoting School policy that includes integration with the School Health Services,
•	lobbying for resources and support to implement the School Health Services policy, and
•	the development of protocols for training, a training manual to ensure standardised implementation, and health manuals for teachers.

These are all crucial to the success of the policy, and require urgent attention as none of these had been successfully achieved at the time of writing.

Links were established with the DoE with the aim of establishing a multi-disciplinary Provincial Task Team to inform and support implementation, monitoring and evaluation. The DoE's ‘Implementation Plan for Tirisano’ (May, 2000) called for a collaborative approach to service delivery to develop optimum personal and social development. There was clear support from the DoE's Service Delivery Support Services, and this needed to be developed into practical collaboration at district level.

This study investigated the capacity and resources of the 11 districts in Kwazulu-Natal for implementing the Kwazulu-Natal SHP. It aimed to establish which systems and structures were already in place, and what would be required from districts in order to implement this SHP and Implementation Guidelines. The researchers examined coordinating structures, human and equipment resources, clinical protocols, referral and support systems, training and development programmes and information, education and communication materials. They also looked at the extent to which districts were already achieving the objectives of the KwaZulu-Natal SHP and Guidelines, the qualifications of staff, their training needs, and the preparedness of nurses and other categories of staff to implement the health assessment and other aspects of the policy and guidelines.

2. Methods

The situational analysis included interviews, a questionnaire and focus group discussions at both provincial and district levels. Provincial programme managers in health, education and social development were interviewed to explore what they could contribute to implementing the School Health Services. Members of the School Health Teams in each district completed the questionnaire. The researchers visited each district to investigate its priorities, services, resources, and future plans to meet School Health targets. Focus group discussions to explore the perceptions of teachers, school governing bodies, parents and pupils were held in three districts (Ugu, Umgungundlovu and Zululand), which were selected as being representative of other districts in the province. In each of these districts three primary and two high schools were randomly selected and visits were made to each of the 15 schools.

3. Results

3.1 Provincial level inputs

Three provincial departments were targeted in this study: Health, Education, and Social Development.

3.1.1 Department of Health

Representatives of various directorates of the KwaZulu-Natal DoH who were to be involved in implementing the SHP offered the following information in their interviews.

The Maternal, Child and Women's Health Directorate

In the Health Sector, the Health Promoting School Programme already offered an opportunity to provide a coordinated approach. It integrated service provision by ensuring that teachers, who saw the pupils on a daily basis, were trained in aspects of basic health in order to identify problems. Teachers could contact the School Health Teams for further assistance when necessary. In the Education Sector there were similar policies in respect of health education for topics such as HIV/AIDS, substance abuse and child abuse. Although there were more than enough professional nurses (there were 38, and the staffing norms for the 11 districts in Kwazulu-Natal require 35), extra personnel were urgently needed in order to meet the targets of the KwaZulu-Natal SHP. For example in terms of staffing norms 169 health teachers were required, but only 44 were currently employed. More suitable vehicles were also needed to reach children in distant schools throughout the province.

The Health Promotion Directorate

The Health Promotion Directorate suggested a practical modus operandi for the SHP in each of the 11 districts. Several schools could be linked to the nearest clinic, and the teachers could act as mediators, notifying the clinic about urgent health problems at the school so that a School Health Team or Mobile Clinic Team could attend to them. The team would visit each school at least twice a year, first to screen children and examine those with problems identified by teachers and on the second visit follow up on referrals. The team would also encourage the schools to participate in the Health Promoting Schools initiative and help to develop a programme with the school community to elicit the participation of other stakeholders (Environmental Health Officers, Community Health Workers, social workers, agricultural officers, South African Police Services).

The Nutrition Directorate

The Nutrition Directorate advised that the type of food given to the children in school nutrition programmes should be continuously monitored, and that the service should be available to all children who needed it, at both primary and secondary schools. They proposed that the Department of Education be supported in its efforts by the Department of Health through advice and the latest information regarding nutrition.

The Mental Health Directorate

The Mental Health Directorate said the School Health Teams should be targeted for training nurses to assess school children, identify problems and recommend interventions. There should be regular workshops for the teachers in the schools to promote awareness and update them on their role in providing a stable environment for children and identifying problems. They advised strong intersectoral collaboration between their Directorate and other departments to achieve high standards of mental health.

3.1.2 Department of Social Development

The Department of Social Development saw its role as follows. In the short term, it would provide intermediary services to support school social work services and awareness programmes; in the medium term it would form interschool forums with relevant role players to address service delivery to schools; and in the longer term it would plan, implement and evaluate preventive programmes and support services. The forums would have to be reviewed in order to encourage progress on the programmes implemented.

3.1.3 Department of Education

The Department of Education explained that the School Health Services were part of the provincial strategic planning and policy issues and fell mainly under Service Delivery Support Services. The issues that affected health were seen as very serious, and likely to continue to plague the health of both pupils and teachers, particularly HIV/AIDS and drug and alcohol abuse. School health was part of the Minister of Education's broader vision – it was aligned to Health and Safety and the political leadership had identified this as a priority.

3.2 District level inputs

At the district level, data was gathered from existing School Health Teams and teachers in schools.

3.2.1 Findings from the questionnaire completed by School Health Teams

The form of the School Health Teams varied throughout KwaZulu-Natal because of their histories. Little transformation of the teams had taken place since 1994 and thus they largely resembled those of the apartheid years. Teams that served previously white, coloured and Indian schools usually had two nurses each and were able to meet their targets by getting to all the schools annually. Teams from the former Department of Education and Training (DET) schools (for black pupils only in non-homeland areas) were reasonably well equipped and were able to service all the schools in their charge efficiently. Ex-KwaZulu teams were based at provincial hospitals.2 They had heavy workloads, were poorly supervised and could reach few of their allocated schools. At the time of writing, integration of the various teams under a single authority had not been successful and the teams were proceeding much as they had done previously.

Responses to the questionnaire were received from 10 of the 11 districts in KwaZulu-Natal. No teams were operating in the 11th district at the time. A total of 43 completed questionnaires (just over 50%) were returned from the entire province. Selected responses are reported below.

Description of the sample

The School Health Teams in KwaZulu-Natal consisted of 82 personnel to service over 4000 schools in total. Almost half of the team members (38) were professional nurses and 44 had other qualifications. All except two of the teams had at least one professional nurse. Of the 43 respondents the majority (36) were women. The total number of years in service varied from 10 months to 26 years, with a mean of eight years.

School coverage

There was a wide range in the number of schools per district (from about 265 to 624) and also in the number visited by the teams (from 46 to 293). The number of teams per district was not always proportional to the number of schools. In only two districts were teams reaching more than 40% of schools annually and in a further two districts over 30%. Almost half of the teams reached less than 20% of their schools per year. From some districts the information was limited – one district did not have a team but only a nurse supported Health Promoting Schools in the district once a week. Three districts had three, four and six teams targeting 429, 375 and 258 schools and reporting visits to 80 (19%), 30 (8%) and 58 (22%) schools respectively. Data from the other seven districts are shown in Table 1.

Table 1: KwaZulu-Natal School Health Teams' targets and visits to schools, 2004

KwaZulu-Natal district	Number of School Health Teams	Total number of schools	Schools targeted, n (%)	Schools visited, n (%)
1	3	318	197 (62)	70 (22)
2	5	426	278 (65)	147 (35)
3	7	487	292 (60)	191 (39)
4	2	265	50 (19)	46 (17)
5	5	577	476 (82)	266 (46)
6	5	479	330 (69)	293 (61)
7	2	624	77 (12)	75 (11)

Rate of child referrals for further medical treatment

Only a small proportion (15%) of the children referred for further medical assessment are actually followed up, and in the various districts there is a wide range in the number of children reached, referred for further treatment and subsequently followed up by the teams to monitor their progress.

Equipment

All the teams appeared to have sufficient equipment for basic health assessment – stethoscope, otoscope, height measuring stick, measuring tapes, eye charts, forceps, hand basin and thermometer – and in most cases the equipment was in good working condition.

Transport

Data indicated that transport was a major problem. Many of the teams used vehicles from the hospital pool and frequently failed to obtain a vehicle since the vehicles were needed for other clinical services as well and were often not available (40% of the teams had to share a vehicle with other health workers). The lack of vehicles often prevented them from making appointments with schools as they risked failing to keep them. The schools in the districts were scattered over a wide area, many of them with untarred roads that made access difficult in rainy weather. Half of the teams travelled one and a half to two hours to reach their furthest schools. Another problem was the risk of hijacking – team members often felt insecure travelling on roads where vehicles were frequently stolen.

3.2.2 Findings of the focus group discussions with teachers

Most of the 15 schools visited by the researchers for the situational analysis were in outlying areas and nine of them had not been visited by the teams. At the high schools there was a perception that only primary schools were targeted by teams and so they were not surprised that they had not been visited. Three primary schools confirmed that they had also not been visited. Despite this, the principals and teachers of all the schools visited thought there should be a closer working relationship with the School Health Teams. All agreed that this would benefit the pupils.

The main health problem identified by all the teacher groups was poverty and many spoke of the effects of malnutrition. Typical comments were:

No food is sent with the child. (Female primary school teacher)

There is little food for children after school. (Another female primary school teacher)

Primary school teachers said scabies and other skin ailments were prevalent. They referred children to the clinic or, if the case was serious, to the nearest hospital. Some teachers from a few of the schools felt that the School Health Services had responded to their call for assistance adequately and written referral letters, which expedited treatment. However, at some of the rural schools the teachers emphasised the problem of health facilities being so far away – in some cases up to 20 kilometres from the school – and the lack of transport. Many expressed their feelings about the extra burden of having to see that the children got fed and received medical attention, when they themselves had limited diagnostic knowledge.

The same topics came up in the discussion groups at all the 15 schools: the high unemployment rate, high rates of illiteracy among parents, the lack of basic facilities and the scourge of HIV/AIDS. The teachers highlighted the problem of people suffering from HIV/AIDS and the way children are affected when parents are sick or die:

Kids are staying alone and that is one of the problems we are facing – there is no one that is older at home. There is neither a mother nor a father. (Male primary school teacher)

These community problems affected the teaching environment and increased the teachers' stress, as one teacher explained:

We have no trained person – we teachers also need counselling for stress.

In addition some of the children themselves were sick.

The lack of effective information about HIV/AIDS available to pupils was also perceived to be a serious problem. At one of the schools a female teacher explained that they themselves felt inadequate in dealing with sexuality:

Sexuality is hard for us to talk about – we are shy. It is not our culture.

As a result, at many of the schools the teachers requested help with this area of teaching:

There are no people to counsel kids about HIV/AIDS. As a matter of fact, this year alone there are many children who have fallen pregnant. This tells you that condoms are not used and those people are at risk of getting HIV/AIDS. (Male high school teacher)

We are coming from a society where talking to a child about sex is taboo. So you can imagine the kind of environment, where children have sexually transmitted diseases. (Female primary school teacher)

Also raised in one of the discussions was the topic of belief in witchcraft, which was a barrier to coping with the HIV/AIDS epidemic:

People do not yet want to accept that this disease is here. They still have excuses like ‘I have been bewitched’. (Female primary school teacher)

Some schools continue to lack essentials such as water, and although the water supply has improved in the area around some schools so that fewer children have to go to the river, water is still not available on site. The resulting lack of hygiene was stressed by many of the teachers in rural schools:

Water is our main health problem – it affects us all, the pupils and the teachers. (Female primary school teacher)

The inadequate sanitation in many of the schools was another problem:

We don't have water here at school – as a result the toilets are always dirty. (Primary school teacher)

The children sometimes have diarrhoea since they don't have water to clean their hands. (Female primary school teacher)

Members of the school governing bodies emphasised their need for School Health Services and parents and pupils confirmed the problems highlighted by the teachers. They all saw provision of vehicles for the School Health Team as a necessity and felt that the authorities in the districts should ensure that each team had a vehicle so that they could provide the required services.

4. Discussion

4.1 Human resources

The situational analysis suggests that there are enough professional nurses but not enough other team members in many districts in terms of the pupil:School Health Team ratio norms of one provider to 7000 Grade R/Grade 1 pupils, and one provider to 15 000 older pupils. It may be possible to achieve these ratios when it comes to the actual screening tasks of the professional nurse, but when these norms were set they did not take into account the difficulties of reaching rural schools, which are situated far away from the teams' home base. The team:pupil ratio (DoH, 2004) does not appear to take cognisance of the different topography that results in long journeys. Many of the schools servicing the Kwazulu-Natal population are in distant areas of the province and difficult to reach because of poor roads (Taylor et al., 1997).

4.2 Transport

The time taken to travel to and from the schools each day leaves little time available for health assessments and health education. A further constraint is inefficient access to vehicles, not only the difficulty of obtaining a vehicle from the transport pool but also the need, for security reasons, to keep the vehicles in secure premises, which are not necessarily convenient to access. Thus teams often leave the base late and travel a long way to schools that close early in the afternoon, which limits their work time. Increasing the number of team members will mean that even more vehicles will be required in future. The availability of transport and the suitability of vehicles is therefore an important issue. Ideally teams should have their own vehicles for travelling to the schools.

4.3 Training

The teams require a wide range of training in order to implement the SHP. A training package based on the SHP's Essential Care Package is needed. The situational analysis identified the need for extra personnel for health promotion and health education and this can be achieved in collaboration with other departments and sectors taking part in this initiative. For Health Education to be effective, the teams will require training and appropriate information, education and communication materials. It was found that teams often provide information in a didactic manner, but many studies have shown that information alone is insufficient to achieve behaviour change (Green & Kreuter, 1991). Pupils need to understand that they are personally at risk and to be taught the skills to reduce this risk.

4.4 Screening of children

A longer-term goal is to ensure that children are carefully examined at clinics before they start school. In fact, they need to be fully screened during their five-year immunisation visit. Many teachers said they could identify children with vision, hearing or neuro-cognitive problems, and that these children could then be referred to the School Health Nurse for screening and referrals.

4.5 Training of teachers

This is an essential component of the SHP and standard protocols are required. For example, it is teachers who routinely provide First Aid to pupils. New School Health Teams would therefore require prior in-service training in First Aid. Identifying interested teachers and linking the team with a coordinator at the school could help ensure better First Aid services at the schools.

South Africa's District Health System requires each district to develop an integrated development plan, so it is essential that the school governing bodies work with the councillors in their areas to ensure that the needs of their communities are included in the plan. It is a major problem that so many schools still lack basic facilities such as clean water and adequate sanitation, and an intersectoral approach to ensure that these problems are solved is urgently required. The DoH and the DoE in collaboration should be helping to find a solution.

Many teachers at the schools visited said they would like to be part of the solution so as to assist in improving the pupils' health. District School Health Coordinators are needed to facilitate integrated planning and development of the School Health Services within the framework of the Provincial SHP and Implementation Guidelines. They should develop best practice models based on local needs and available resources. Both the district and programme managers emphasised the need for additional human resources and vehicles in order to achieve the policy objectives. Liaison between the teams and the DoE and other service organisations would be required to ensure integrated services within the Primary Health Care/Health Promoting School framework, and to monitor and evaluate targets, inputs, outputs and outcomes in collaboration with the DoE. For this they would need to set up the necessary structures and systems and identify target schools on the basis of district health needs and baseline data.

5. Conclusion

The situational analysis reported in this paper describes the current state of school health services in KwaZulu-Natal and explains what is required to implement the SHP. It has shown that there is much to be done to achieve this implementation. A report on health behaviour in school-aged children in Europe (WHO, 2004) identifies problems similar to those experienced among South African children: substance abuse, risky sexual behaviour, insufficient physical activity and weight problems. It suggests that joint action by government, civil society, international agencies, parents and young people is required in order to reduce these risks. In South Africa there are additional problems with the burden of disease. It is therefore important that the SHP be comprehensively implemented, and this will only be achieved through collaboration between departments and sectors.

Acknowledgements

The authors would like to thank the KwaZulu-Natal District Management and School Health Teams; the principals, teachers, parents and pupils at the schools; and the research assistants who collected the data. They also thank the Italian Co-operation for funding the study.

Notes

¹Few children in South Africa have the opportunity of attending preschool facilities. To address this the government has initiated a pre-school Reception year (Grade R) for children turning five years of age.

²In apartheid South Africa school health services were provided by different structures. The DET serviced black schools in urban areas and rural schools were visited by staff from the KwaZulu administration (hence described here as ex-KwaZulu).