Cape T~
SBCOMD CARNEGIE INQUIRY INTO. POVER'l'Y AND DBVBLOPMEN'l' IN SOUTHERN APRIcA
by
·Brici kti
• CZiJ:n8!i1e QmfCft:i'i03 ~
".'99
13 .. 19 April 19t4
-,,"
:. :;-...
ISBN 0 7992 0715 2
I,.,au'
G., .... I. Is •••• , Snth "rlu" ._aU" ·"Iac • • t.tn~. The IIhai. district It •• is.lah4 I.hnd .i ... , htw ... "!s,ratt .. 4 h... It It t"leal " ... 14 .Ith 1i.ltt4 •• tn •• 4 , • ., "rlevlh,1I ,oto.tlli. IU.OOO , .. , h 11 .. I. 1:II.Ia'. 57 .lIla,1I which IIr, I ••. i . . . . 4 I,.,n.tr"'t... ..~It
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'th ...
tn. ttlcllnlet . . . 11t cll.ic •
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t • • , ...ru.a1 h"lth ... k. The ,0 ... lIIt h ••• ".,.,14 . . . rhu ••• 'lul "h . . lt t. ,",c_ 1 ... 10 ... In ru •• 1 h"lth Urt •• d ... d.ligute" sc ... t. , •• ticular • .... la ..
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So •• b.u •• In, .... d in Ga ... h ud tho Health Sor.iell D ••• Io, ••• t U"lt '"SOU). a "..j.ct ., the Wits D.,art ... t .f C ••• ".it, Moalth . . . to"lhht4. Tho ,bj.etio . . . f t . . . ,,It . r t the tral.l . . . , ."ropri.t, ... 1th It.,let .t.ff. the
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lon .... d .... ., •• nt " cll"ic .... lc ... th, crtltt. " • h .. lth •••• Ieo .hich II c •••• "it' .. "ertl .. u4 .npouh. to ·Ioc" ... ds. T. ,,,cc •• 4 ... the , .. chlill .... " •• t ." ... 1I,.et .f the ...,,It,
.n4 the ... I.hi.ted bac.h, .f the uhtln, h .. lth .... leo.Thh pa,er .... th. otho . . . f the HSOU .re refltctio . . . . nal, . . . co ... ti ... d I ... a"d ••• the p.oduct ., .u' fi .. t ho , .... ' •• perhneo. O,lnion. IIpre .. 1Id .re baud •• the critical · ... I,.h
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herd d.t • • n tilt ew. h.n' .nd Oft
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nal I",",iou on the other. llhat ...r
the .,1.1.". It II ... "Kq~l .. d '" fi .. t hand ."d •• atal .. 4 p ... i •• ,eritnct.
The ,.p ... co ... th ... IIptell ., .u . . . ,erhftCl:.
1. Th, State .f Nt.1 th ,"d Kill til C ... In !!h.I.
•. H .. lt~ .nd H.alth C ... in "hala .n o .... i ...
b. Th. htritional Stat.,
0'
Children 1 - 5,II".
l. A Critlqu •• , So .. Health S ... lct Inte.vutlo", ·in IIhal.
•• C ....
"it,
Hlllth W ... I" "hala : P ... 1Oft0'
a P.o' .... h. C.llc.,t7 b. Hov •• ll do ou. Ru •• l Clinica Functio,,?c •. H .. hvin, th, H .. lth C.nt .. Pollc,.
d. lIebll.Clinie, : IIhat can .nd do the, Achi ... ? 3. Health Service Into ... ntlo, .. b, tho tits HSOU
•• D. Prill., HIIlth C ... h ... , in Gu.n.ulu p.owid. SlCond Cla .. Che., C.rt h til. P ... 7 b. Can ,ood Tube.culo,i' S ... icII be provid.d i" tho F.ct .f Pnert,?
c. School Htllth S, .. iell • '.obla .. and P.osp.cts.
d. Na .. I.auni .. tion Ca.p.l,n, - Th. fillt ••• 1t b,eritnc ••
The ... ,. h th.t:
- Hlllth c ... in llhala II In.d.quate.
This care c.n b. 1.,.0 .. 41 vithnt p .. ctdin, changll in the p .... "t icon .. ie and pilitlcal ."te ••.
- Such i.pro .... "t Is llaihd b, ,ocial. 1C0no.ie and political eon,t.aints vhlell .rt the
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c .... of aueh llln ....
- It is vo.th .. orking ill "h ... lalld· hlllth lI.vlu, bee,uII ., ... t can b. achinld.
In ackno.ltdglng .11 .ho h.WI .o ••• d i" or vith HSOU it ••• t b . . . b ... d that htllth lI.vice d ... lop .. "t is • t . . . . ffo.t. IIIn,.' the p.oph ., IIh.la. th' hOI,ltal .taf'. ,r.l .. rll, 0 ... St.ph.n .. n ., ,up.rinhnd.nt and tho co .. unity hllith "u ... D. Erica Satter .... the superlntend.nll
."41
ataff ., Gazanhh'. other hospitals. thl h.alth 4.part . . nt ltd b, Dr Roos ud.'0"
recentl,. D. Robert •• nd the Chitf IIlnhh • • , G.unhutu haWi .ll cont.ihhd t. tilt .. hUhh .. nt .nd d ... lop.nt of the Unit. Th. Ch.I ... n" hnd0'
Angl. A .. rie.n .lId the U"hlr,lt, .,. theIIlt •• tt ... h ... '"yi .... the in' •• ,t.actu ...
The .ction ha, co •• , ... blta .114 ... '.ch"toll. t.1c ''''h. Reb C.lli ... eNrlc .. ' ' ' ' . Cliv. hi.", Vic 'erd •• k. IIer.,1 Hu.o"d. Th.h lIalultka. SIII.It, 11 ... " ..
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IIIIU .. l •• llt.t . . ; Dip •• II ... Roh.t IIn,h alld IIerrlc. ha .. ",ttln.JO""
SUR DIR[CTDR - MSDU IIARCH 1914./
SCIIOOL HEAL TIl SE:lV ICES - PROBLEMS AIID PROSI'ECTS
Eric 8uch
The 57 primary schools in Mhala had 16 064 Sub A and Sub 8 pupils In 1982. The teacher pupil ratio was 1 : 62,0. Most teachers are not qualified. Many classrooms have inadequate lighting and only spaces for windows. As there are too few classrooms, many children learn under a tree - If It rains or Is cold.
school ·is cancelled for the day. Schools have no water facnltles and either a few i,nsanitary toilets, or none at all.
School heal th services were started by Tfntswalo hospital In May 1982. The service aims to screen for dfsease and treat the problems found, llIIprove the school environment, train teachers In health and health care. and develop Child-to-child programmes for children to learn about and improve health. let us look at these four functions in more .detall.
WHAT CAN SCHOOL HEALTH SERVICES IN THE UNDERDEVElOPED WORLD DO?
Screen for disease
Children in the underdeveloped world have much undetected and untreated disease. This is due to extensive 111 health in the community. and poor access to and Inadequate .quallty care. These factors make screening services In schools especially Important.·
The purpose of screening is not Just to find health prabllllls, but to ensure that approprfate action is taken f n response to these findings. In fact, for a screening service to be worthwhile it·should meet the following six criteria (1):
The tests used should be sln::ple.and acceptable to the children and their parents.
Important health problems should be found.
The problems would not otherwise be detected and treated.
The problems found are treatable.
It is co~t-beneficial to treat the diseases.
The health service can cope with the load of providing care.
2.
The health servfce cln cope with the load of proyfdfng care.
leproye the school envfronmant
The physfcal envfrom::ent at schools fn the underdeyeloped ..orld is often unsathhctory. Many chfldren are taught under trees, IS they hlye no clusl"OOlllS. Classl'"OO:3S often hue inadequate lfghting and only spaces for wfndows. Many schools have no toilets or water hcfl f tf es.
A school health service should take actfon to iaprove the physfcal envfron=ent at schools.
Develop Chfld-to-child programmes
The fdea in Child-to-child activities is that older children gain an interest in health through helping" their younger brothers and sisters. For example, they could care for thetll when they have diarrhoea, llllke toys to enhance their developlllent, preyent accidents by improving safety at home, and i~roye their neighbourhood by acting agafnst pollution.
Good Chfl d-to-ch1l d programes can encourage chfl dren to recognise that they have the abfl tty to change and improve the sf tuatf on that they live in. They will take part in activities that help to bu1ld important value systems such as helping one another. In the long term these experi ences wi 11 help them become better parents and better lllelllbers of thei r cOlllllUni ty.
Train teachers
Resource constraints on school health services" in the underdeveloped world llean that they usually only reach a 51:1111 proportfon of schoolchildren, Ind then only once a"year. Probleas outsfde of "these times wi 11 need to be solved by those who Ire there - the school teachers. Volunteer teachers undergo training 1n sfmple aspects of screenfng, prfDiry clre, health education and runnfng Chfld-to-chfld progralCll!S.
3.
HHAT HAS HAPPEtJED IN TINTSWAlO'S SCHOOL HEALTH SERVICE THUS FAR?
It W,I~ noterl carl ier that school heal th services were started by Tints.lo in I-lay 1982. They were pI anned to i ncl ude screeni ng, enwi ron;aental. teacher training, and Child-to-child services. In developing the service we have faced a number of problems. This· section describes these probletlS, and outl ines our solutions if they have been solved. It also describes our plans for unsolved problems and our prospects for the future.
Thus far, only screening services have been initfated.
schoolchildren have been screened.
The screening service
2 609 Sub A and Sub
If we compare our experience with the criteria given earlier for justifying screening for disease we find that school health screening is worthwhile.
Simple and acceptable tests
The tests performed are all simple, and acceptable to the children and their parents. An abbreviated general examination is done on all children. The illiterate E test is used for vision, PPO for tuberculosis, and protein in the urine for bflharzfa (200 urines of children who had protein in their urine were tested - bilharzia ova were found in over 97t;.) Because of the limited skills and equipment available, we have had to limit hearing testing to the "whisper test"
and to use only a mouth inspection for dental caries.
Important health problems
Important health problems were found. 46,1S of Children have PPO's of 15mm or above, 39,6\ had had no food before coming to school, 16,11 had bilharzia, ll,5t; had obvious dental caries on lIIOuth fnspection, and 4,5% ... had skin infections. A wide range of other probletlS occ.urred, all in less than
n
of the children.4.
Probleas would reali" "ndetected and untreated
Not only were iraportant heal til probleals found; ft is likely tIIat DOst of .tlle diseases would hive rGOIined undetected and ufttreitod 1f not for the scllool health service.
Treatable conditions
Most of the condi ti ons we found can be treated wi th icproved end.
results. Specific guidelfnes have been developed for the care of coc::non probleA1S.* SOlIe probleas are beyond our .ans to troat. Th1s is consfdered undor 'load' below.
Cost-benefic1 al
It is certafnly cost- beneffcfal to care for the probleas found. The sfngle school health teaa costs us about R12 000 per annua to run.
Thls f1 gure is aade up of R7 000 for staff. and R2 500 each for supplies and transport. Wefghed against the benefit of treating disease early and the lost learning abflfty of children with health problems, the price fs cheap.
Load within health service means
The final criteria is whether the health services can cope with the problems found. The answer is ·yes· except for bilharzia, nutritional problems, dental caries, and the need for tuberculosis treatctnt.
Prazfquantel, used for bflharzfa treatment, is expensfve (R3,70 per treltcent). We are therefore only able to treat the coro severe cases.
When it coats to nutrition
we
are really at a loss. Trying to arrange handouts of food at schools is not a solution to the blstc problea of poverty, but there is lfttle else that can be done through a school hellth service. Even so, ft is beyond our resources to organise 1school health feeding program=t.
*
Ootatls Ivaflable froa the luthor.5.
Tintswalo hH only recently acquired a dentist and dental equipment.
The service cannot cope with the enormous load of dental caries in schoolchlldren; so, we restrict ourselves to only caring for serious cases e.g. root exposures.
On the bash of our current data we estimate that there are nearly 8 000 children in sub-A and sub-8 in Mhala who require tuberculosfs care. As we do not have the resources to tackle this massive task, we tried the alternative of arranging supervision
0'
care through school teachers. Unfortunately it was i"'Practical. 138 out of the 338 children at one school needed care. The teachers were very willing, but spent more than 2 hours a day supervising care instead of teaching. The support we had to give to keep this effort going could also not be achieved again. We have therefore had to decide that we will only provide T8 care for about 15S of the children needing it.The decisions outlined for care of bilharzia, malnutrition, dental caries, and tuberculosis were difficult to make but we had no choice. Doing more than we have described would have drawn of' scarce resources from other parts of the health service.
The workload
Ideally,chfldren should be screened three times at primary school. We have found that if our school health nurse and her assistant are working optimally, they can screen and care for an average of 80 children a week.
Based on a 40 week school year, they can only reach 3 200 of the 9 248 children in sub-A. In response we have started a second school health team, but we will still only reach 70S of the sub-A's, and no children a second or third time.
6.
Staffing
We have just potnted out that tVOf! with a second school health teaa, we will only screen half the Sub-A's. Therefore, not only wtll our screentng- be fnadequate to aeet the need, but for the forse.able future we will have to shelve envfro/Ctntal ieprovement, teacher training, Ind Cltild-to-c:htld prograc:es. Th. school health service needs at least 8 registered nurses. We can IlIOtivata for posts for extra staff, but thfs takes tflllt and
we
Day not get thell. Even ff we do,we
Day not have the skf1led staff avaflable to ffl1 the posts.There have been probleas of skfll and productfvfty. We made the mistake of assuafng that a public health nurse would have skl1ls that she did" not" and have since designed and run a 3 week course.
As the school health nurse works with ltttle supervfsion she has to ensure her own J:IOthatfon and discipline. Ve have had problems such as cuttfng corners when screening. poorly kept records" and leavfng work early. In 1982 t~e school health nurse worked at some distance from the hospital and cared for only 8 chf1dren a day. In 1983 she worl(ed at schools near the hospftal, and was more supervfsed, and Mlnaged • rate of 18 a
day.
When we started the school health service our matrons, instead of choosfng froa the most reliable ·and dYnamfc workers. chose one who had worked poorly fn other departments. They thought that her specific interest fn school hea 1 th waul d 1 ead to good work. It df dn' t. Ve lllade _ sure
we
chose a relfable and ~naafc second school health nurse.Support systems
The school health servfce has had a vehfcle sfnce ft began, but we don't have another one for our new teall. Thfs has 1 ed to serf ous dfsrupt i on of thefr work. Our prospects of gettfng one through the h.llth servfces are rec:ote, so w. wfll be lookfng towards outsfde dOnors.
OUr early attempts at record systeas were clumsy. We have sfnce tested and finaHsed a record systemwhfch is workfng wel1.*
*
Detafls avaflable froa the.luthor.7.
Initi~l1y W~ rfid not h~vf' our drtJ~<; and supplies or~anised. We hilve now developed equiplnent and drug lists and specHic guiclelines for Clre of common problems.*
At the outset we underestimated the amount of supervision and support that woul d be requi red. After some ups and downs these systeas Ire stronger.
They operate under the routine managelllentof the nurSing service. A weekly doctor's visit also helps.
cmlCLUSION
There is no doubt I n our mi nds that school health services are an important component of health care in the homelands. However, the service w111 remain 1 imi ted to one that screens about half the· Sub-A chi 1 dren, unless adequate staff and transport become available. The needs for environmental fmprovenent, teacher training, and Child-to-child programmes will remain unmet.
The service needs 8 registered nurses each with a vehicle.. If we did allocate these resources now the school health service would be developed at the expense of other areas. The hospital would be left with only two vehicles. and either the clinics would lose all or the hospital wards half of their registered nurses. And yet, school health services llleet an important need, a need that will not diminish until health in our area improves. This hlProvement is In turn dependent on the reduction of poverty.
REFERENCES:
1. Sackett D.L. "Laboratory screening: A critique",
Federation .. Pro~~edfng~, 34 : 12, 1975, 2157 - 2161.
• O('tails avail
TINTSWAlO HOSPITAL SCHOOL HEALTH SERVICE
~RY Of GUIDELIIt[$"OF'ACTIOlt TO TAKE FOR PA08lEMS rOUl:O
Problea
No
breakfast
.
Wei~ht/~geless tl!a,!l
801Hei gilt/age
1ess than
801Urine posithe for protfen (Bt1harztl)
Hearfng
Vfsion
PPO test"
(for tuberculosfs fnfectfon)
Anaellfa
Skfn, eye, ear and throat fnfectfons.
Pellagra Dental carfes
Heart .nWlr
Abnonul chest sounds.
Undescended testies
Hydrocoele or fngu1nll heMlia.
Mental health probleas including retardatfon and epilepsy. "
H.i story of worcts
1_ : r ~ -". ~
. Action
"
---"
Nfl
, If clfnfcally severe, refer
tohospftal •
,Nfl.
Treat with praziquantel
if 2+protefn, passing blood clots or has pafn on aicturttfon. Otherwfse no treatcent.
If a cause found, treat ft and re- examine.
If no cause refer to doctor who
~refer to Pretorfa.
If
6/9or less refer to opthalafc nurse, who may refer to visiting
opthalmologist.
If
23mmor above arrange
6months of supervised care by the school teacher.
Use
~nahas per protocol.
If lS-2lna, leave.
If less than
5mmgive a BCG.
Ghe fron and to take as per protocol.
Treat
ISper protocol.
Give nicotanfmfde as per protocol.
Refer root exposures and other severe carfes to the dentists.
If less severe, no" treat;ent.
Refer. to doctor.
Refer to doctor.
Refer to ·doctor.
Refer to psychfatrfc teaa.
Ghe thfabendazole as per protocol.
Note:
2.
3.
l ". r ~
2.
'.
,".
~-Specific patient care guidelines (protocols) are avaflable for all'the problems.
The fact that,a problem does not get tre~ted does not c:ean that we
do
not' see ft as a problem. It raelns ~atwe
are not fn • ·position to cope wfth it •• ,T i~·. .-::, "-.",-'
