Integrated School Health Programme: Department of Health briefing

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21 August 2013
Chairperson: Mr B Goqwana (ANC)
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Meeting Summary

The Department of Health (the Department) briefed the Portfolio Committee on the Integrated School Health Programme (ISHP), which was a joint activity undertaken by the Department of Health and the Department of Basic Education (DBE), which had grown from the school health policy launched by President Zuma in 2012. A joint task team had been meeting weekly to coordinate the activities of both departments. In addition, there was a need for increased involvement of the Department of Social Development (DSD) in relation to early childhood development. The objective of the ISHP was to reach all learners, offering health promotion and education, individual learner assessment and treatment, provision of services on site at schools, the opportunity for referrals and follow-ups, and to do an environmental assessment of schools to ensure that they had sanitation, clean water and safety fencing. The package of services offered to the learners under the health promotion and education would include individual assessments that could focus on any barriers to learning, education and offering of sexual reproductive health services, with an emphasis on abstinence and delayed sexual debut, although in terms of the Children’s Act any child over 12 years old was entitled to either be permitted to purchase condoms or be offered other prophylactics. In addition, TB screening would be done, and, at the higher levels, there would be services for mental health and psycho-social vulnerability. On site services at schools would also include immunisation, de-worming, dental and oral care and the treatment of minor ailments. Physical activity was encouraged and promoted, and counselling would be given on tobacco, alcohol, obesity and drugs. HIV Counselling and testing could be provided by the school nurse, who would keep records and could refer on to a healthcare facility.

The implementation model was that task teams would be set up at national, provincial and district levels, that school health teams would visit, with support from a Support Team. Specialist mobile units had already been deployed to the ten National Health Insurance (NHI) pilot districts. At provincial level, it was intended to recruit retired nurses. 80% of schools targeted were visited, and 30 vehicles had been purchased, with donor funding, whilst 60 more were planned. Coverage of secondary school learners was slow in taking off, because of shortages of personnel and equipment, and it was noted that consent to offer the School Reproductive Health Services had to be approved by School Governing Bodies. This, and outreach to learners, would be fast-tracked. Stakeholder partnerships would be improved.

Members were appreciative of the presentation, but raised a number o concerns. Several Members enquired why the School Governing Body had such strong authority over implementation of a Departmental programme. They questioned the wisdom of deploying older nurses only, suggested that other plans be made, asked about the staff shortages, and whether the rural communities and farm schools were being reached. They asked about the mobile clinics, any challenges in any particular provinces, the recruitment strategy for doctors to work in rural areas, and the number of school nurses provided to each community, and their collaboration with nurses at local clinics. They questioned the budget, and the provincial allocation of that budget, asked if there was an organogram, and asked which unions were represented in the joint meeting. Members asked about plans for sanitary health at schools, and the plans to improve the measurement and quality of training. They commented that the Department of Social Development needed to be involved to address poverty issues, and that it would be useful to involve South African Police Services (SAPS) on issues of drug use and child abuse. Members asked what role loveLife was to play, and what agreements had been signed. The Department indicated that it would be shortly bringing further reports also to the Committee.

Meeting report

Chairperson’s opening remarks
The Chairperson welcomed the team from the Department of Health (DOH or the Department) and noted that the Committee had been briefed, a while back, on the Integrated School Health Programme (ISHP). The Committee wanted to know more details on it, what it entailed, its progress and any challenges.

Integrated School Health Programme (ISHP): Department of Health briefing
Ms Malebona Matsoso, Director General, Department of Health reminded the Committee that the Integrated School Health Programme (ISHP) was a joint activity undertaken by the Department of Health (DOH) and the Department of Basic Education (DBE). In January 2011, a joint task team was established and this had been meeting on a weekly basis, to coordinate the activities of both departments. She said another element that was important for the Department was to bring in the Department of Social Development (DSD) on the early childhood development (ECD) aspects.

Dr Nonhlanhla Dlamini, Chief Director: Child, Youth and School Health, Department of Health, thanked the Director General for the background introduction. She explained that a New School Health Policy was launched by President Zuma in October 2012. This policy represented one of three streams of Primary Health Care re-engineering. Within the education sector, Care and Support for Teaching and Learning were important components.

The new Integrated School Health Policy replaced the 2003 School Health Policy. On 10 September 2012, a joint meeting comprising the Minister of Health, the Minister of Basic Education, Deputy Ministers and all senior management of these Departments was convened. The purpose of the meeting was to obtain consensus and a common understanding of the ISHP and the service package. The objective of the ISHP was to reach all learners with the following package of services:
- Health promotion and education
- Individual learner assessment and treatment
- On-site provision of services
- Referral and follow-up
- Environmental assessment of schools

The ISHP aimed to assess each learner once in each educational phase, from Grade R to Grade 10.

The package of services offered by the ISHP included:
- Individual learner assessments, with a focus on barrier to learning
- Sexual and Reproductive Health and Rights, with an emphasis on abstinence and delayed sexual debut
- TB screening
- Barriers to learning
- Mental Health and psychosocial vulnerability (in the senior school phases and at FET phase)

Dr Dlamini explained that on-site services offered at schools included immunisation, de-worming, dental and oral care and the treatment of minor ailments. The environmental assessment of schools was intended to create linkages and ensure that schools had sanitation, clean water, and fencing in order to promote and create a safe schooling environment. Information and counselling was also given pertaining to tobacco, alcohol, obesity and drugs. Physical activity and exercise were also promoted and encouraged. The school health nurse conducted HIV Counselling and Testing (HCT) together with confidential counselling. Where necessary, that person would facilitate referral to a health facility for follow-up care, support and treatment. Records were kept by the school health nurse.

Dr Dlamini explained that the Children’s Act No 38 of 2005 had been amended to include access to contraceptives for children over the age of 12 years, citing section 134 (2) of the Act, which stated that “contraceptives, other than condoms, may be provided to a child on request by the child and without the consent of the parent or care-giver of the child.”

Dr Dlamini explained the implementation model for the ISHP. The ISHP Task Teams were established at national, provincial and district levels. School health teams would therefore visit schools in the designated areas and these visits would be facilitated by the School Based Support Team (SBST). In addition, Specialised School Health Mobile Units had already been deployed, starting in the ten National Health Insurance (NHI) pilot districts. At a provincial level, she said that retired nurses would be deployed and/or redeployed for the new programme.

Dr Dlamini described the progress to date. The establishment of ISHP task teams at national and provincial levels was the main achievement. Guidelines and training packages for school health nurses were developed and training had taken place in all provinces. The Department of Health was also able to achieve an 80% target for schools visited. In addition, 30 vehicles had been purchased for the mobile clinics initiative, at district levels. The purchasing of the vehicles was achieved through a partnership between the Department and the European Union. The Department was still in the process of purchasing 60 additional vehicles.

Dr Dlamini said that although coverage of Grade R/1 learners had increased substantially, coverage of secondary school learners still remained a challenge. Shortages of additional school health nurses, transport, medication and equipment were still a concern. The Department needed to obtain approval from each school’s governing body, even though the Department of Basic Education had agreed in principle that School Reproductive Health (SRH) services could be provided in schools. Reporting and collaboration of data had also been a problem. In addition, the implementation of the programme in some provinces and districts remained weak, as a result of insufficient health nurses and the lack of transport.

She concluded that some of the priorities for 2013/14 were continued emphasis on reaching secondary school learners. Agreements with school governing bodies for the delivery of SRH services needed to be fast-tracked. Resource availability needed to be strengthened. Stakeholder partnerships, such as those with loveLife and Soul City’s Soul Buddies needed to be improved. Collaboration between the Department of Health, the Department of Basic Education and the Department of Social Development also needed to be monitored and improved. The HPV vaccine would also be introduced in 2014/15.

The Chairperson thanked the Department for the presentation and for this report which would assist the Committee in further monitoring the Department’s work.  He asked who had the final say when it came to the implementation of the SRH programme, saying he was worried by the implication that the  School Governing Bodies (SGB) had such great control. He argued that in many cases, members of SGBs were not that literate and asked how the Department would balance their decisions with more informed ones. He made the point, however, that SGBs were not the same in all schools in the country as some, particularly in the Model C schools, were better informed than those in public or rural schools.

Ms T Kenye (ANC) thanked the Department. She referred to the environmental assessment of schools, and asked whether there was enough human capital to do these assessments. She was concerned that the shortage in vehicles for transportation was one of the major challenges to the implementation of the ISHP and wondered if , and how, the 30 vehicles were distributed efficiently throughout the provinces.

Ms Kenye raised a concern about the sustainability of the programme if the Department was only focusing on redeploying retired nurses, and said that the Department should perhaps think of planning also to incorporate young nurses into the programme, particularly since school learners might be more comfortable communicating with someone closer to their own age. She asked if there was an organogram for the schools-based support team.

Ms Kenye asked about the DOH’s recruitment strategy for doctors to work in rural areas, asked how the Department would ensure that rural clinics were well catered for.

The Chairperson reminded the Committee that the Minister of Health was admitted to a public hospital a while back, and this Committee had written to him congratulating him on using a public hospital and wishing him a speedy recovery.

The Chairperson informed the Department that the Committee had just visited hospitals in the North West and would be forwarding a report to the Department in due course on this visit.

Ms C Dube (ANC) raised a concern about some provinces which did not seem to be performing well, and asked for more detail on some of the implementation challenges at provincial level, and which  provinces posed the greatest implementation challenges. She wondered which unions were represented in the joint meeting which took place on the 10 September 2012.

Ms Dube asked about the plans that the Department had to improve the measurement and quality of training. She further wanted to know what plans the Department had in place to address sanitary health at schools, especially pertaining to the use and disposal of sanitary towels. She noted the use of retired nurses, but asked for more detail on the Department’s recruitment strategy.

Ms M Segale-Diswai (ANC) asked how the Department interacted directly with communities, especially the rural communities. Commenting on stakeholder consultation, she said the Department of Social Development needed to be included in the partnership with the Department of Health and the Department of Basic Education. Poverty at schools was a serious concern, which needed to be tackled as a matter of urgency. Child-headed households were also on the rise. The South African Police Services (SAPS) also needed to be included when addressing issues of drug use and child abuse.

Ms Segale-Diswai asked what plans the Department had to address the issue of staff shortages and budget constraints. She asked for the numbers of school nurses in each community, and how they would collaborate with nurses at local clinics. She wondered how the Department was reaching schools in farm areas.

Ms Segale-Diswai was also interested in questions asked earlier, about the distribution of vehicles, and why the implementation of the SRH programme seemed solely dependent on the SGB approval.

Ms P Kopane (DA) thanked the Department for the presentation. She argued that the success of any project depended on the resources available to it. She asked whether the Department had put aside a set budget for the programme, and whether there was enough money available to sustain it. This led to a question on how much money was allocated per province. In regard to sexual reproductive health, she asked how rapidly the Department could fast track the process, and what were the timelines.  She asked what role loveLife would be playing in the ISHP. She also wondered whether parents were being consulted before the programme was fully implemented.

The Chairperson said primary health care was a very important programme, and the budget indeed needed to be discussed.

Ms Dube referred to the Children’s Act, and asked for clarity on what the Act meant in section 134(1)(a) when it stated that “No person may refuse to sell condoms to a child over the age of 12 years”.

Ms Kopane asked whether there were any Memorandums of Understanding signed by the Department and other stakeholders.

Ms Matsoso firstly replied to the question on environmental health, noting that the programme was launched in October, when, in addition, the District Health Specialists Units were also established. These were incorporated into the school health programme. She explained that within the school health programme there was a team with an environmental health practitioner. She said the Department had come up with an integrated model to tackle a number of issues, and would like to have an opportunity to present the integrated model to the Committee. A special “Health in All” policy had been drafted by the Department and the Committee would be briefed on it shortly. The policy was also used for Higher Education as a tool to tackle health matters at that level.

Ms Matsoso wanted to emphasise the distinction between primary care and primary health care. Primary care happened when people were given services at health facilities. Primary health care was when the social determinants of health were tackled, such as access to clean water. The Department of Health would then partner up with relevant other departments to address matters such as these. She said the Eastern Cape was currently the only province which produced Environmental Health Specialists.

Ms Matsoso responded to questions on the retired nurses, saying that the idea behind recruiting older nurses was to have enough nurses to kick-start the programme, and this category was a very useful resource. She agreed that older nurses were not necessarily the best equipped to talk to young school learners about sexual health, and in one province, the school learners had actually been reprimanded by elderly nurses when they went to enquire about sexual health. The Department was aware of these challenges and would be addressing them.

Ms Matsoso said that assessing simple nurse to community ratios was currently not that practical, especially when broken down between developed and developing country. The World Health Organisation had come up with a tool which took into account a number of factors, such as the burden of disease, the work load, the type of service and the population size. The ISHP therefore took into account all these variables in order to determine doctor-nurse rations. She agreed that there were some facilities which were presently over staffed, but the integrated model would attempt to tackle such matters. The mobile clinics were one solution. She explained that the Department had partnerships at a strategic level and there were instances where joint policy discussions took place. At an operational level, joint task teams were established. At these levels, formal mechanisms for implementation were discussed.

In relation to questions around transport and the mobile clinics, Ms Matsoso confirmed that the Department had conducted an analysis. It was clear that in certain areas, mobile clinics would not be able to operate, especially in rural communities. However, because the Department was using development aid money, it had bought vehicles. There was a shortage of drivers. The next vehicles which would be purchased would be linked to agreements around drivers. She argued that the Department had a broader implementation plan for transport facilities. She added that child mortality had been reducing in rural communities, and that was something which the Department was proud to announce.

Dr Dlamini responded to the question on the organogram for the school health task team, noting that the team was headed by a professional nurse, who was assisted by an enrolled nurse. Where possible, there was also an oral hygienist. Dentists and other professionals were shared throughout the fixed health facility. She gave the ratio as being one school health team for 2 000 learners. The environmental health practitioners were also shared among the schools.

Ms Matsoso made the point that at national level, the Department did not have contact with local communities, but that the ward-based services would be introduced by municipalities. An integrated approach was devised by the Department, in order to deal with the social determinants of health. One of the main objectives of the Department was to improve primary health at community level.

Dr Dlamini responded to the question around challenges, saying that the provinces with the most challenges were the Northern Cape, the North West and the Eastern Cape. She said the Department worked very closely with the Department of Social Development to address matters pertaining to orphans and vulnerable children. She agreed that for the farm schools, the school health teams and enrolled nurses were very important.

In relation to the School Governing Body involvement, Dr Dlamini noted that the health toolkit needed to be approved by the SGB. The task team was co-chaired by the Department of Basic Education. Although the Department of Health had signed off the toolkit, the SGB still had to approve it. The vision of the Department was that every school principal must have the toolkit. She reminded Committee Members that parents were part of the Departments’ consultation process because they were part of the School Governing Body (SGB). There were also consent forms which the learners had to take back for the parents to sign.

loveLife assisted the Department because peer educators from loveLife were brought into schools to talk about matters such as sexual health. The same peer educators who educated learners on school grounds could also be found assisting young people when they visited the clinics. In relation to the Children’s Act requirements she clarified that section 134 meant that if a child aged 12 years or older wanted to purchase condoms, he/she should be allowed to do so and did not need any consent from his or her parents.

Dr Dlamini informed the Committee that the next task team meeting was on Monday, 26 August 2013, and the distribution date for the toolkits was one of the items on the agenda. As soon as a decision was taken, the Committee would be given a report. She said the reason why there was a low coverage at high schools at the moment was because the programme was only targeted for primary school learners initially, and had only recently been introduced to high school learners.

Ms Matsoso replied to the question about unions, noting that the South African Democratic Teachers’ Union (SADTU) and the SA Onderwysersunie (SAOU) were some of the unions which took part in the stakeholder consultation processes. All legislation teams on child health were chaired by the Department of Justice and Constitutional Development, but the Maternal and Child Health legal team from DOH were also active in the legal processes. She agreed that the area of early childhood development was one which needed even more attention from the Department. She acknowledged that the school nutrition programme had proved to be working very well. The food fortification programme had also shown very good results. She added that some skills would be contracted from the private sector, where the need arose.

Ms Kopane suggested that the Department consider bringing back the school radio so that communities were kept informed of what was going on at schools.

The Chairperson thanked the Department for the engagement. He announced that a major financial company was looking to appoint a health practitioner to manage the African region, and he encouraged Members to apply.

The Chairperson informed Members of an upcoming study tour to countries which were mainly surviving on tobacco production, such as Malawi.

The meeting was adjourned.


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