Substance use is rife amongst adolescents, including learners. Learners are easily exposed to substances with onset as early as 10 years and average age of drug experimentation is 12 years in South Africa. This results in many negative health and social outcomes, a challenge as far as the achievement of global, regional and national goals such as quality education. The revised Integrated School Health Policy (ISHP) is a policy operating within the school environment aiming to address health and social barriers of learners and improve optimal health, comprising a vague action component on substance use prevention. This article is an opinion piece, which uses the Walt and Gilson model as an operational framework to analyse the revised ISHP within the lens of substance use. It assesses the four interrelated aspects: policy context, policy content, policy actors, and the policy process. The ISHP is placed within schools where adolescents are found and has the potential to reduce many health challenges such as substance use amongst learners. However, some issues are left to chance, such as health education on substance use prevention stated to only begin at Grade 4 (10 years), little mention of parental involvement, limited interplay amongst actors, limited investment in upskilling educators on dealing with substance use, scarce resources for implementation in all developmental phases and provinces to address substance use. Intervention can be more comprehensive with an intersectoral political approach needed to ensure that implementation addresses all multiple levels of influence of substance use amongst learners and the numerous health and social barriers.
Substance use amongst adolescents in South Africa (SA) (majority of them are in school) is an escalating public health concern, with an early age of onset (10 years)
Simultaneously, young people’s access to health promotion initiatives varies widely during formative years.
This article is a brief analysis of the revised ISHP in SA with a lens on substance use.
The comprehensive
The analysis also draws on the University of Western Cape (UWC) School of Public Health (SOPH)
A summary analysis of the policy context, policy content and actors of the revised integrated school health policy.
Category of issue | Issues raised | Issue links to/influences over other issues |
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Context | South African government committed to put children first | Signatory to the convention on the rights of the child |
Policy framed within a global, regional and national context | Adapted many regional instruments and embedded within the framework of relevant policies: Millennium development goals now Sustainable Development goals, 2000 EFA Dakar Framework for Action to achieve Education for All, Care and Support for Teaching and Learning Program, The Health Promoting Schools Programs (HPSP) | |
Most children are in rural areas and live under the income poverty line; depend on social grants; child headed households; access to basic services limited; oral health-tooth decay; HIV and AIDS; mental health; substance use; crime; trauma and violence |
The context still remains the same. | |
Substance use increased use and prevalence of dagga use very high |
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Substance use is still a priority risk behaviour amongst learners. | ||
Structures proposed from a national to school level (national, provincial, district, facility and school-based task teams) | There is limited intersectoral implementation | |
Content | Vision, goal, objectives, target group and those not covered by the school health programme | Vision and target group the same as from the previous policy |
Goal phrased differently but has not significantly changed from the previous policy except for collaboration | ||
School health package of services: |
Limited resources affecting implementation |
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The mention of drug and substance use comes as a sub-item under mental health on the health education and health promotion. It is one of the topics to be covered under life orientation and co-curricular activities. As a result of an increased prevalence, it should be itemised as a bullet on its own to receive the much-needed attention as with other priority issues. | ||
Under school health package services, substance use is mentioned under health education starting from intermediate phase (Grade 4–6) and going on to senior phase (Grade 7–9) and FET phase (Grade 10–12). This is a missed opportunity for early health education to prevent experimentation and initial use as statistics indicate early onset of substance use by learners. | ||
Implementation guidelines and structures at national, provincial, district, PHC facility and school level | Resource package for School health nurse available | |
Mention of the monitoring and evaluation plan | - | |
Actors | Ministry of Health and Ministry of Education. | Policymakers and key actors in implementation |
School health nurse -implementers at the schools with collaborators | Shortage of nursing staff in the health system | |
Department of Social Development | Key collaborators | |
Learners from Grade R to Grade 12 | Target group/Beneficiaries |
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Non-governmental organisations (NGOs) such as UNICEF |
Collaborators:assistance in finalisation of the policy, resource package for the school nurse and appraisal of the previous policy | |
Section 27, Equal Education | Pressure groups |
EFA, Education for all; HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; PHC, primary health care; UNICEF, United Nations Children’s Fund; UNFPA, United Nations Population Fund; FET, Further Education Training; NGO, non-governmental organisation.
A myriad of challenges exists in the school environment including the persistent rise of substance use by learners. The policy context seems favourable to address the health and social barriers faced by learners because many legislative frameworks are aligned and incorporated within the revised ISHP.
The revised ISHP was introduced as a framework for the new school health programme, implemented at sub-district level in 2012. The policy came in after a historical background of segregation and inequalities pre-2000. Post-apartheid led to the development of the 2003 National School Health Policy to redress the historical background of inequalities in school health. School health did not improve much and some failures were attributed to a lack of collaboration and the policy reduced to a DOH initiative despite initial efforts by many actors, which included researchers. The ISHP is a revised initiative located within national, regional and global frameworks to promote education and health
Although the ISHP outlines the role of respective departments in addressing the health needs of learners to ensure a strong school health service, literature suggests that there is stagnancy in implementation and working in silos of sectors.
The analysis of the following policy characteristics of the ISHP helps to get an understanding of the policy goal and objectives in the prevention of substance use by learners:
The South African president recognised the school health programme during the 2010 nation address leading to the launch of the revised ISHP in 2012.
The school health nurse from the nearest health facility, together with a team plays a key role in the implementation of the school health programme but is not always available owing to the shortage of health workers. Another important actor that should be on the forefront to receive training is the parent or guardian, barely mentioned in the policy and often, only involved when the problem has escalated. If parents are empowered regularly, they can detect and solve a lot of issues at family level. Educators are found at the frontline of dealing with learners abusing substances and are often not adequately equipped to respond effectively to the challenges such as early detection of substance use. Similar to a resource package for the school health nurses,
From an ecological perspective, substance use amongst learners cannot only be addressed through mental health assessment and health education because of the multiple levels of influence. A study describing compliance of ISHP in terms of collaboration in Tshwane highlighted ‘insufficient stakeholder integration’ in the implementation of the policy.
A chronological order of the process of change of the ISHP is summarised in
A summary analysis of the process of change of the revised integrated school health policy.
Category of issue | Issues raised | Issue links to/influences over other issues |
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Processes of policy change |
2003: National School health policy (NSHP) launched | A means to rectify the differentiated school health services emanating from the apartheid era, poor reach, under resourced, poor collaboration. |
2009: Health and education policy reforms which included school health | The policy is embedded in the health sectors’ response to strengthen through re-engineering PHC and the education sector through the CSTL programme. | |
2010: A directive from the president to reinstate school health programme through the 2010 Nation Address | More actors were involved in assisting with finalising the policy and resource package for the school health nurse: UNFPA, UNICEF. | |
2012: The ISHP launched as revision from the 2003 NSHP and revised from the 2011 NSHP | A shift to planned better collaboration between the DOE and DOH and DSD. Policy co-signed by both DOE and DOH. Department of health provides services and DOE creates enabling environment. | |
2020 | Policy implementation still has insufficient integrated intervention; skills and expertise required for implementation. |
PHC, primary health care; UNICEF, United Nations Children’s Fund; UNFPA, United Nations Population Fund; DOE, Department of Education; DOH, Department of Health; ISHP, integrated school health policy; CSTL, Care and Support for Teaching Learning; DSD, Department of Social Development.
A quick comparison of the 2003 NSHP and 2012 ISHP highlights the improved scope of the inclusion of substance use prevention allocated under the health education and health promotion component, with health education to begin from intermediate phase (Grade 4–6) up to FET phase (Grade 10–12). The 2012 policy specifies for the health education to be part of Life Orientation and co-curricular activities. However, prevalence rates of substance use remain unchanged and, in some provinces, increasing amongst learners. There is a need for more detailed content for upskilling players on the prevention substance use. Simultaneously flexible collaborative activities for buy in of implementers and fostering collaboration with other role players in addressing substance use should be developed. The ISHP is potentially placed to address the determinants of health and development within school children, as it incorporates progressive health reforms such as comprehensive PHC and the Care and Support for Teaching Learning (CSTL) framework.
Several departments were placed under central government administration including health and social development affecting resource availability
There were disparities in the implementation of the ISHP as not every school has school health nurses visiting and school health services implemented in certain phases, which means that not all students are screened and referred timeously. It may mean late intervention for learners abusing substances.
Inadequate training for school managers and educators who are unaware or have a vague understanding of the ISHP has implications for coordinated activities to reduce substance use.
Intersectoral collaboration is still very slow with a lot of sectors working on substance use prevention in silo programmes.
The following points are for consideration:
An integrated political approach is needed to address substance use amongst learners with different sectors, with the revised ISHP broadening as a joint initiative that includes more sectors such as police, justice, social development to ensure that implementation addresses the multiple levels of influence onset of substance use.
There is a need for expertise such as counselling and school-based social workers to timely identify mental and social problems, which may result in substance use. These should work with the school health nurse and ensure timely referral and intervention.
Regular training of educators and parents on anti-substance use prevention approaches and a significant component of parental involvement on policy implementation including substance use to operationalise it at school and community level.
The revised ISHP is grounded in the school environment with great potential to address many health and social challenges of learners. Intersectoral collaboration for the implementation of the ISHP with commitment and resources is imperative in order to address the multiple levels of influence of substance use amongst learners. Substance use is an increasing epidemic causing havoc in learner’s lives. If existing policies and sectors interplay effectively with the ISHP, substance use can be curbed amongst adolescents.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
L.S. took lead in writing this manuscript and F.W. provided critical feedback and contributed to the writing of the manuscript.
This article followed all ethical standards for research without direct contact with human or animal subjects.
As part of PhD studies, this work is supported by the Belgian Directorate General for Development Cooperation, through its Framework Agreement with the Institute for Tropical Medicine (grant reference: FA4 DGD-ITM 2017-2020) and the South African Research Chairs Initiative of the Department of Science and Technology and National Research Foundation of South Africa (grant number: 82769).
Data sharing is not applicable to this article, as no new data were created or analysed in this study.
The views expressed in this article are of the authors and do not reflect the opinions of any university or institution.