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Implementers of this policy also reported a number of challenges or constraints associated with the implementation of this policy. A brief summary of the challenges or constraints encountered is presented in Box 3 on below:

Box 3: Challenges and or constraints faced by implementers in implementing this policy

Systemic challenges (e.g. long waiting times; staff shortages, poverty, large class sizes etc) requiring intervention at national government level

Lack of parental involvement in school health matters

Ideological differences amongst actors/stakeholders regarding the value of school health services

Lack of a dedicated budget for school health services

A. Systemic problems that require the intervention at national government level These were the challenges that could not be addressed effectively at district level, as

highlighted in the box 3 above. Comments from key informants are shared below:

i. Long waiting times at the health facility

“Most of our learners don’t have medical aid, so when they need medical attention, they have to go and wait in long lines at the clinic…” -(Key informant 1).

ii. Poverty and other social problems amongst the school community members

“Most of our parents here will tell you that we are not working, we don’t have the money to take the child here and there, we are unemployed. That is our main concern, unemployment of our parents in this area.” -(Key informant 3).

“For instance there’s such a lot of social problems and when I get to the school it’s as if I am the social worker..” - (Key informant

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iii. Large class sizes, therefore making educators job challenging

“You see we all sit with classes 40+ children in our classes, at the end of the day the curriculum does come first.”- (Key informant

2).

iv. Shortage of nursing personnel

“We are supposed to be 5 teams in X (name withheld), we are 4 teams. Because of the other uncovered areas, Y and Z (names withheld), we divided those schools amongst us, so we both got extra schools…” -(Key Informant 7).

B. Lack of parent’s involvement in their children’s health matters

Lack of parental involvement in school health matters was cited by educators as one

of the key challenges:

“You see we can set the appointment also but if the parent does not

follow up…, a lot of them are unemployed, but some of them do work and their bosses may not allow them time off.” -(Key informant 2).

C. Ideological difference amongst stakeholders regarding the value of school health and implementation of the school health policy

Some implementers pointed out that there are still some managers in the DOH

who are opposed to the idea of having school health services:

“There’s a lot of people within the department, top managers that believe that school health service should not exist. And I’m not talking here middle management level, I’m also talking top management level where people see this as a service that’s wasting the health department’s budget on healthy children.”-(Key Informant 6).

Key informants reported that the DOH has started to put some pressure on nurses to see more children. School health nurses reported feeling this pressure:

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“…as I said the only thing is I don’t like this rush, I don’t like this pressure, we have to see this amount of learners and then we have to move onto the next school. Because they want us by this year July to reach the target and I don’t know if we’ll reach the target.” - (Key

informant 7)

D. No dedicated budget to provide school health services

There are several costs associated with the provision of school health services that

schools have to bear. These costs may include procuring and maintaining a well

replenished first aid box, paying for staff members to be trained on first aid, and so

on. With the exception of a once off sum of R1000 for the 2008 school year from the

DOH, schools do not get a dedicated budget from either the DOE or the DOH for

expenses:

“We don’t get money from the department [DOE], within our own

budget we see what we are able to provid ..” –Key informant 2

“No, we don’t, from the DOH side, the facility like X, gets a budget

and whatever budget facility X have we are included in that budget, but there is not a budget that says, this money is allocated to school health..” – (Key informant 7).

While the historically disadvantaged school relies on nurses from DOH to provide services, the suburban school has found some innovative ways of providing high quality school health services in their school. This is done by making parents pay a special fee, called a testing fee:

“What we do is the parents pay an additional sum, say it’s like R300,

its not a deposit for entrance, it’s for a testing fee …and during the course of the year, while they are in Grade R, they will have, all the children will have: ears tested, eyes tested etc, just basic tests….”- (Key informant 4).

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This school also make arrangements with different health professionals or organisations to provide services to the learners at a discounted fee:

…, because we are finding more and more children require things like

occupational therapy.... about 8 or 9 years ago an occupational therapy practice, the lady approached me and asked if we would have accommodation for that practice at the school. And so they have been with us for about 8 years. But they’re private; we give them sort of board and lodging so the fees are low.” (Key informant 4).

And also in addition to that, we employed a part-time psychologist originally she shared between another school and ourselves for three days; we now have her 5 days a week ‘til 12 o’clock. I don’t know what we would do without her; she actually does a lot of additional work. We now have a second psychologist that comes in twice a week. We also have a speech and language therapist who started three years ago … our speech and language therapist is an audiologist as well, also private practice.” (Key informant 4).

3.3.1 Suggestions for Improving Implementation Process

When participants were asked to give suggestions on how could the implementation of

this policy be improved, almost all of them felt that provision of these services will be

better if they were provided by resident professionals. That is, nurses and other

professionals who provide these services should be based at their respective schools:

“I would love to work at the school to be employed.….to be placed in the school and then I would sustain health in the school because if you try to maintain, I must be honest we try to maintain health in the schools with what we are doing as far as this policy is concerned. To maintain health not sustaining health ,and the only way to sustain it is to be there constantly.”- (Key informant 7).

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“Ideally, each school should have its own school health nurse, psychologist, social worker, and community health worker.” (Key

informant 1).