School Health Policy and Implementation Guidelines February 2011 Contents Page Foreword 3 Acknowledgements 4 Glossary of terms 5 Acronyms 6 Executive summary 8 section 1: the school health policy 10-32



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School Health Policy

and

Implementation Guidelines

February 2011

Contents


Page
Foreword 3

Acknowledgements 4

Glossary of terms 5

Acronyms 6

Executive summary 8
SECTION 1: THE SCHOOL HEALTH POLICY 10-32
1.1 Introduction 11

1.1.1 Background 11

1.1.2 Socio -economic and health factors of school aged children 12

1.1.3 Rationale for a School Health Policy 16

1.1.4 The policy review process 16

1.1.5 Situation analysis 17


1.2 School Health Policy 23

1.2.1 Vision 23

1.2.2 Goal 23

1.2.3 Principles 23

1.2.4 Objectives 24

1.2.5 Summary of Strategies 24

1.2.6 School Health Services Package 24

1.2.7 Target group 27


1.3 Institutional Framework for the Implementation of the School Health Policy 28

1.3.1 Organization of the system 28

1.3.2 Planning and management 28
1.4 Monitoring and evaluation 31
SECTION 2: IMPLEMENTATION GUIDELINES 33-42
2.1 Introduction 34

2.1.1 Summary of key recommendations 34


2.2 Implementation context 35
2.3 Critical success factors 35
2.4 Responsibilities at national, provincial and district level 36
2.5 Staffing the service 39

REFERENCES 43

Foreword
It is with great pleasure that we present the revised National School Health Policy and Implementation Guidelines, which responds to the needs of learners in all learning sites, to ensure their optimal growth and development.
Having signed the United Nations’ Convention on the Rights of the Child (UNCRC), South Africa has joined the global village in putting children first’. This means the State has an obligation to ensure that all segments of society work towards optimum investment in the health, education and social well-being of children, in order for them to develop into successful adult citizens.
For children to maximally benefit from the education programmes, they must be healthy. This strong linkage between health and education, therefore, identifies the school as an opportune environment, where the children’s health and well-being can be addressed. Furthermore, it is critical to strengthen collaboration between the Departments of Health and Basic Education, other government departments, civil society, the private sector and relevant development partners. Through coordinated efforts, the country can achieve long term gains of reduction in morbidity and mortality amongst children and young people.
The main pillar of this policy rests upon an integrated approach within the comprehensive primary health care package. Therefore, actualizing implementation of this policy will ensure that all school going children, including those in remote areas, have access to quality health services.
We would like to acknowledge the work of many health workers and educators, whose untiring commitment continues to make a positive impact on the lives of children. We also thank everyone who has participated in the review of this important policy and implementation guidelines.
Let us all remember that the level of development of any country is measured by the health status of its children.
Dr A Motsoaledi Ms A Motshekga

Minister of Health Minister of Basic Education

Acknowledgement
The National Department of Health extends sincere gratitude to all who contributed to the review of the School Health Policy and Implementation Guidelines (2003).
Special appreciation is directed to the Provinces, Academic Institutions, Non-Governmental Organisations, relevant Government Departments and Development Partners.
The Department further acknowledges the World Health Organization (WHO) Country Officer for the technical support provided through the services of Madame Odete Cossa (WHO/ Inter-country Support Team).
Glossary of terms
School health programme

Based on the WHO description, the school health programme is a combination of services ensuring the physical, mental and social well-being of learners so as to maximize their learning capabilities.


Health Promoting Schools Initiative

A broader initiative facilitating implementation of comprehensive school based programmes, with a critical focus on empowering the entire school community.


Integrated service

A service located within the administrative, functional structures and resources of comprehensive primary health care services.


Learners

School-aged children attending schools and other structured learning sites.


School community

The entire community involved directly or indirectly with a school i.e. learners, parents/caregivers, educators, school management (including the principal and members of the school governing body), administrative personnel and other auxiliary staff.


Target group

The main beneficiaries of this policy are all children attending learning sites, regardless of age.


Vertical service

A specialised service that operates separately from other primary health care services, within a separate administrative structure and with its own resources.



Acronyms
ART

Anti Retroviral Treatment


CHPI

Child Health Policy Institute (now Children’s Institute)


UNCRC

United Nations Convention on the Rights of the Child


DOBE

Department of Basic Education


EPI

Expanded Programme on Immunisation


HPS

Health Promoting Schools


IMCI

Integrated Management of Childhood Illness


NDOH

National Department of Health


NGOs

Non-governmental Organisations


NHC

National Health Council


NPA

National Programme of Action for Children in South Africa


NSDA
Negotiated Service Delivery Agreement
PHC

Primary Health Care


PPA

Provincial Programme of Action for Children in South Africa


SHP

School Health Programme


SHS

School Health Services


YFS

Youth Friendly Services


YRBS

Youth Risk Behaviour Survey


WHO/SA

World Health Organisation/ South Africa


WHO/AFRO

World Health Organisation/ Africa Regional Office



Executive summary
According to the World Health Organisation, school health programmes can reduce common health problems in learners, thereby increasing the efficiency of the educational system. The WHO Expert Committee on School Health confirms that school health programmes can advance public health, education, social and economic development. The global expansion of school health programmes attests to the value placed internationally on such programmes. 1
For children to benefit from the education programmes, they need to be healthy. This strong link between health and education therefore, identifies schools as a perfect environment where the children’s well being can be supported and maintained.
Having ratified the United Nations’ Convention on the Rights of the Child (UNCRC), 1996, South Africa has joined the global village in prioritizing children. 2 The UNCRC as well as the Constitution of South Africa (Act 108 of 1996), highlights the importance of adopting a ‘rights based’ approach in implementation of the School Health Programme.3
Furthermore, the implementation of this programme requires a multi disciplinary effort to ensure comprehensive care to all learners in schools. The benefits of targeting the school population include increased public awareness, community participation and sustainability of implemented programmes.
Currently the majority of learners in the country, especially in the remote disadvantaged communities, do not receive school health services. In a few districts where this service is provided, challenges mainly of inadequate human resources and transport create barriers to implementation.
The school health policy therefore aims to provide a clear framework on what the school health programmes entail and how it could be implemented.
Vision
The optimal health and development of school-going children and the communities in which they live and learn.
Goal
To contribute to the improvement of the general state of health of school-going children as well as the environmental conditions in schools and address health barriers to learning.
Objectives
General Objective
To guide the provision of a comprehensive, integrated school health programme that operates within the framework of the Health Promoting Schools Initiative.
Specific Objectives


  1. To provide preventive and promotive services that address the health needs of school-going children, including those children who have missed the opportunity to access services during their pre-school years.




  1. To provide schools health services.




  1. To support the school community in creating health promoting schools.




  1. To support educators and school health nurses in their school health activities.




  1. To ensure sustainable coordination and multi-sectoral partnership.




  1. To mobilize resources for the implementation of the school health policy.


Institutional framework for implementation of the School Health Policy
Implementation of the school health policy requires strong inter-sectoral collaboration with different sectors. Most importantly, the key Departments of Health (DoH), Basic Education (DoBE) and Social Development should form the basis for implementation of this policy. However, relevant government departments, academia, civil society and partner organizations are expected to contribute in sustaining comprehensive school health programmes.
Monitoring and evaluation of the school health programme will be integrated within the district health information system as well as interfacing with the education information system. The policy contains a set of indicators for monitoring the school health programme, which, in this revised policy, will measure implementation at sub district level.
Implementation guidelines
The implementation guidelines section of this document outlines the implementation framework which can be amended to suite the workstation at local level. A list of responsibilities for the Department of Health is provided for the co-ordination and development of the school health programme at the national, provincial and local levels.
School health is a non-negotiable integral part of the comprehensive package of primary health care services that must be delivered to every school in the district.
The guidelines further provide the requirements in terms of the district structure, management, delivery, staffing, training and supervision. In addition, the guidelines outline categories of staff required for successful sub district level implementation of this policy.


SECTION 1:


SCHOOL HEALTH POLICY
1.1 INTRODUCTION
1.1.1 Background
The South African Government has pledged to “put children first” by becoming signatories to the United Nations Convention on the Rights of the Child (UNCRC) 2 and by according children special recognition in the Bill of Rights of the South African Constitution.3 This commitment aims at ensuring that the rights of children are upheld and provision is made to enable them to reach their full potential. This is important especially during the formative school years, wherein, providing special attention to their optimal health will improve their survival, growth and development.
In order to realize children’s right to health, a number of policies and programmes have been formulated, based on the principles of primary health care (PHC). This approach embodies all elements of health care, with specific emphasis on preventive and promotive health care.5
A comprehensive school health programme allows children access to health promotion and education during their early years of learning. It also allows for the identification of potential barriers to learning and thus maximizes children‘s learning potential.
Developing a comprehensive school health programme poses challenges of integrating activities that focus on children of school-going age, within and outside the health sector.
The 2009 Education Statistics in South Africa showed that 12 227 963 learners were enrolled in schools in the country.6 This number is likely to increase as the transformation and strengthening of the education system enables it to retain more learners for longer.
The School Health Policy and Implementation Guidelines 2003 adopted a phased approach to implementation. The phased approach, which focused on district level implementation, did not translate into school and learner coverage. Furthermore, district level implementation masked the low sub-district coverage. The revised policy will focus on comprehensive sub district level implementation thereby replacing the phased approach. This will facilitate that services reach each individual learner in all the schools within sub - districts.
The current provision of the school health programme in most parts of the country is sub optimal and faces several challenges. This policy takes into consideration these challenges and provides the necessary framework for reorganization of the school health programme.
Definition of school health
Based on WHO description, the school health programme is a combination of services ensuring the physical, mental and social well-being of learners so as to maximize their learning capabilities. The school health policy directly targets all children attending learning sites. This includes the entire school community i.e. staff, parents, the community and learners.1 In the South African context this policy will also include learners in Early Childhood Development (ECD) sites especially were Grade R is attached to formal schools.
1.1.2 SOCIO-ECONOMIC AND HEALTH FACTORS OF SCHOOL-AGED CHILDREN
Socio economic factors
A review of South African literature shows a range of factors that impact negatively on the health and development of children as described below:
Poverty
According to the Child Gauge (2010) seventy percent of South Africa’s children live in rural areas, and many live in households with incomes below the poverty line. Most children depend on the child support grant, mainly due to unemployment and death of one or both parents (orphan-hood). There is also an increase in child-headed households. A number of learners in disadvantaged quintile 1 to 3 schools suffer alarming levels of poverty continue to require government subsidy for exemption from school fees.7
Orphaned and vulnerable children
The 2008 General Household Survey indicates that there were approximately 3.95 million orphans in South Africa. This includes children without a biological mother, father or both parents and accounts for approximately 21% of all children in South Africa. 7
Child headed households
A child-headed household is a household in which all members are younger than 18 years. The older child assumes the role of caring for the siblings. Research suggests that child headed households often exist for a short period for example, after the death of an adult and prior to other child care arrangements being made.6 The challenges experienced are mostly related to poverty, hunger and various forms of abuse, with resultant absenteeism and school drop-out. The role of the school health services becomes critical in collaboration with educators, social workers and the school community in identification and appropriate referral of these children.
Environment
Literature reveals that in South Africa, children’s access to basic sanitation increased from 47% in 2002 to 61% in 2008. Approximately 8 million children still use unventilated pit latrines, buckets or open land. While most children (80%) live in households with access to electricity, many households cannot afford electricity or appliances and continue to rely on unsafe energy sources such as paraffin, wood and coal, which are associated with increased risk of acute respiratory infections and burns. Most schools especially in rural and under privileged areas continue to lack water, sanitation and hand washing facilities. This situation results in spread of diseases e.g., diarrhoea, helminthes and skin infections.7
Hunger and food security
The proportion of children living in households that reported child hunger fell from 30% to 18% between 2002 and 2008. Yet, malnutrition remains common and stunting affects one in five children. Chronic malnutrition has a significant impact on child development, especially during the first three years of life when the brain is still developing. The high prevalence of stunting in this age group is therefore a cause for concern and is likely to have serious implications for future school performance. The school feeding programme, currently located under the Department of Basic Education, makes provision for protecting needy learners from hunger and its consequences.7
Nutritional status
Research has shown that the national prevalence of underweight (weight for age) amongst the under 10 year of age population, was 8.4%; stunting (height for age) was 13.1%, wasting (weight for height) was 4.4%; 19.7% of learners were found to be overweight and 5.3% of learners were classified as obese. The Northern Cape, North West, Limpopo and Free State provinces showed a higher prevalence of under nutrition ranging between 2.6% to 9.1%.8
Early Childhood Development
The Commission on the Social Determinants of Health has called for greater investment in comprehensive early childhood development that links families and young children to health, education and nutrition services. The Children’s Act (Act no 38 of 2005) and National Integrated Plan for ECD provide a framework for the provision of services for children under five, to address children issues of child protection, children’s rights, growth monitoring, immunization, childhood Illness, early learning stimulation, infant and young child feeding, psychosocial care and appropriate referral. 9
Social security
The Child Support Grant (CSG) is a key programme for alleviating child poverty in South Africa. As at May 2010, the CSG supported more than 9.7 million children aged 0-16 years. The beneficiaries are also entitled to free health care services and education.7
Health related factors
Hearing, vision and speech impairment
Hearing and vision impairment are significant barriers to a child’s learning and development.
International literature shows that the prevalence of vision impairment amongst pre-school and school-aged children is between 2, 4% and 6%. It also reveals that refractive errors are the most common visual impairment problems in the paediatric population and many of these are unidentified until children enter schools.9 Furthermore, there is a need for a clear protocol and referral mechanism regarding children that require assistive devices spectacles, hearing aids, wheel chair etc.
A review of the studies on hearing impairment amongst school children in a number of countries show a prevalence of between 4,5% and 6%. It concludes that: “… any school health programme without well-organised audiometric screening neglects an important aspect of child health.”10
Census 2001 conducted by StatsSA showed a disability prevalence of 5% of the general population. And of that 0, 7% is hearing impairment and 0,2% communication or speech impairment.12 South Africa has not conducted specific studies for hearing and communication disorders among school going children to determine the prevalence and incidence rates for these disorders. Kumar and Mello cited an incidence/prevalence of hearing loss in school-age population of about 11.3%, however, they conceded that accurate estimates of incidence and prevalence are difficult to establish because of differences among investigators about the definitions applied, the population sampled, test methods used and the way in which the data were analysed.11
The following studies provide information on hearing and vision impairment and highlight its relevance for school health services in Southern Africa:
A prevalence study of ear and hearing disorders in a sample of grade one schoolchildren in Swaziland found 16, 8% had an ear disorder and 80% had normal hearing. The most common disorder was impacted wax, with a prevalence rate of 74/1000. Middle ear disorders were common, with a prevalence rate of 30/1000 for children with active middle ear disease. Of these, 17/1000 suffered a hearing loss. The prevalence rate for children with inactive middle ear disease was 21/1000 of whom 5/1000 suffered hearing loss; 8/1000 had sensor neural losses, 5,3/1000 unilateral and 2,1/1000 bilateral losses.12
Oral health
The national child oral health survey found that nationally 60% of 6 year old children have dental decay and 55% was treated in 2009.13
The YRBS Report (2008), revealed the following:
Mental health
Substance abuse and risk-taking behaviour are key issues that need to be addressed especially in the adolescent period.

Nationally, 21.4% [19.4 - 23.5] of learners had made one or more suicide attempts in the past six months, with no significant variation by gender or by grade.




  • Substance abuse and risk-taking behaviour




    • Smoking

Research has shown that almost one in three learners (29.5%) reported ever having smoked cigarettes in their life time and one in five learners (21%) were current smokers. Having ever smoked was most prevalent in the Western Cape and Gauteng provinces, whereas current smoking was highest in the Western Cape, Northern Cape and Gauteng provinces, and use of smokeless tobacco was highest in Mpumalanga province, followed by Limpopo and North West provinces.




    • Alcohol

Nationally, one in two learners (49.6%) had drunk at least one drink of alcohol in their lifetime. With respect to age of initiation, 11.9% of learners reported having had their first drink before the age of thirteen years. More males than female learners used alcohol on school property.




    • Drugs

Like alcohol abuse, more male than female learners used dagga on school property. The prevalence of dagga use on school property increased with age. Significantly fewer learners aged 13 years (4.2%) than learners aged 17 years (9.8%) and 19 years or over (11.3%).

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