GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 Indonesian Scholars’ Alliance Open Access Review Children are Losing Lives in the Name of Culture: The Health Impacts of Initiation Schools in South Africa Tiisetso Aubrey Chuene Department of Student Affairs, Student Health and Wellness Centre, University of Limpopo, Sovenga, 0727, South Africa. *Corresponding author’s e-mail: tiisetso.chuene@ul.ac.za DOI: 10.35898/ghmj-72982 ABSTRACT Background: On an annual basis, young boys lose their lives due to circumcisions performed at initiation schools across South Africa. Some of the initiates lose their manhood as a result of amputations and all these acts are done in the name of culture. Over the last few years, there have been more media reports in South Africa about improper traditional circumcisions coupled with poor health outcomes causing deaths of children admitted at initiation schools. Aims: This article explores the health impacts of traditional initiation schools in South Africa. Methods: This review followed desktop approach through utilization of secondary data. Systematic quantitative review technique was used to collect data. To get a better understanding of the context under investigation, desktop analysis was employed using the five steps of the data analysis process. Results: The themes identified in this study include challenges associated with the practice in relation to children’s rights, ethical conflicts between traditional initiation practices and public health, commercialization of initiation schools, and complications associated with circumcision at initiation schools. Conclusion: There is insufficient enforcement of the laws and a lack of public knowledge regarding the impact of initiation on children. Even though South Africa's national and local governments have made significant attempts to control the initiation practices and uphold children's rights, significant law enforcement is still required to shield children from unsafe cultural customs. In addition to the ineffective execution of existing rules and regulations, the traditional initiation sector is burdened by a lack of direct, continuous, and efficient supervision of the operations of initiation schools. Keywords: Supervision of initiation schools; Losing lives; Children; Culture; Male circumcision; Enforcement of laws. Received: 7 February 2024, Reviewed: 11 March 2024, Revised: 29 March 2024, Accepted: 16 April 2024. © Yayasan Aliansi Cendekiawan Indonesia Thailand (Indonesian Scholars’ Alliance). This is an open-access following Creative Commons License Deed - Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) 1. Introduction In South Africa, traditional initiation programs for the circumcision of men constitute a component of South Africa's cultural heritage and are safeguarded by the constitution (South Africa, 1996). Traditional male circumcision is described by Meissner and Buso (2007) as rites of transition in adolescent's transition to manhood. This process is further described by Dyke and Mathew (2017) as the removal of the foreskin from the penis performed by traditional providers for cultural reasons. The custom of traditional circumcision is accepted and practiced in a varied South African community that is defined by multiple traditions. As a transition from childhood to manhood, traditional circumcision is performed by several cultural communities among males in South Africa (Mdhluli et al., 2021). According to Douglas and Maluleke (2018), initiation schools are cultural learning environments used to acquire information regarding social norms, masculine principles, and customary mailto:tiisetso.chuene@ul.ac.za https://doi.org/10.35898/ghmj-72982 Chuene, T.A. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 38 traditions and rituals. Young men who want to learn about their culture's values, beliefs, struggles, respect, and sense of responsibility might go to initiation schools that are cultural institutions (Douglas et al., 2017). This occurs across a clear, predetermined timeframe and it can take place in wintertime or during the summertime. Initiation is one of the oldest customs which is practiced by people from different cultural backgrounds (Silverman, 2004). In South Africa, this custom is followed by Nguni a group which is inclusive of AmaSwati, AmaXhosa, AmaNdebele, and AmaZulu people. According to Hammond-Tooke and Schapera (1974), numerous tribes in the country follow it as well, including the BaPedi, the Southern Sotho people, Tsongas, and VhaVenda. According to Douglas et al. (2017), traditional male circumcision is a sacred and seclusion-based procedure because initiates are not allowed to talk about the custom with non-initiates, and any who do will face harsh punishment from the community. Initiates in a traditional circumcising society go through the initiation rituals so as to be given family and social obligations. Males go through initiation rituals because they are a part of cultural customs within families and communities. The significance of initiation schools in South Africa is highlighted by Ndou-Mammbona, and Mavhandu-Mudzusi (2022) who claim that adolescents who attend initiation schools receive education on social behaviour, cultural norms around marriage and courtship, and standards for societal duty. According to Prusente et al. (2019), males are granted numerous benefits in the community that are linked to their level of maturity upon initiation. In addition, Mohlaloka et al. (2016) state that initiates receive training and instruction on how to be independent and financially autonomous while still making place for the enrichment of less fortunate members of the community. Through initiation schools, the initiates also acquire the concepts of accountability, humanity, respect, and resoluteness (Douglas & Maluleke, 2018). According to Mohlaloka et al. (2016), initiation schools provide adolescents with the skills they will need as adults. These competences align with the official educational framework of South Africa, which seeks to give adolescents the principles, understanding, and abilities needed for self-actualization and significant engagement in society (Department of Basic Education, 2011). The benefits of initiation schools are numerous; however, there are disadvantages as well. On an annual basis, young boys lose their lives due to circumcisions performed at initiation schools across South Africa. During the last 15 years, 858 boys are thought to have died while attending initiation schools, and numerous others have been hospitalized with severe injuries (Centre for Human Rights, 2021). These occurrences amount to a violation of the rights to life, health, physical security, and dignity that the Republic of South Africa's 1996 Constitution protects. In the Eastern Cape province, 11 of the 10 794 boys who attended initiation school in 2022 died during the winter initiation season while 23 of the 51 601 boys died during the summer initiation season (Kamnqa, 2023). Some of the initiates lose their manhood because of amputations and all these acts are done in the name of culture. Over the last few years, there have been more media reports in South Africa about improper traditional circumcisions coupled with poor health outcomes causing deaths of children admitted at initiation schools (Commission for Gender Equality, 2021). Some of the children die at initiation schools annually because of going to unlicensed initiation schools, while others flee their homes and join initiation schools operated by people who are not qualified to execute traditional surgeries and who lack the ability to offer the initiates with professional care after surgery. Young initiates die as a result. This article therefore focuses on traditional male initiation schools which are a topic of concern in the country due to several issues such as deaths, sending children to initiation schools against their will, and in certain situations, sending them without parental permission. While this raises concerns about the children's human rights, the situation is made worse by unfavorable health outcomes that ultimately lead to uncontrolled complications. 2. Methods The review and analysis of secondary data constitute the basis of this conceptual paper. The researcher used a purposive sampling strategy to collect secondary data. To guide this review, the primary question was: what is the impact of traditional initiation schools in South Africa? The question was developed using the Population, Intervention, Comparator, and Outcome (PICO) framework (Schardt et al., 2007). Using techniques outlined by Pickering et al. (2015), a comprehensive literature review was carried out to ascertain the scope of academic research on initiation schools in South Africa. No limitations on research design were imposed in order to guarantee that all pertinent studies were included. Therefore, the incorporation of mixed-methods, qualitative, and quantitative content that was categorized to evaluate the dimension, comprehensive manner, and diversity of literature on the subject was made possible by the use of systematic quantitative review technique. This form of review was shown to be appropriate for summarizing and quantifying the body of research that has already been done, as well as for identifying gaps in knowledge. The review was concluded following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model (Moher et al., (2015). 39 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 Chuene, T.A. To find pertinent studies, different electronic databases such PubMed, Google Scholar, Sabinet, Jstor, EBSCOHost, and Institutional Electronic Theses and Dissertations repositories were systematically searched. The following search terms, either alone or in combination, were used to search for available literature on initiation schools: “initiation schools”, “traditional male circumcision”, “health impacts”, “culture”, “supervision of initiation schools”, “Children rights”. The inclusion criteria were articles related to initiation schools and traditional circumcision of males. Data with ambiguous characteristics and not full paper articles were excluded. Review was limited to the English language and focused predominantly on South Africa. Due to historic relevance of the topic, no restrictions in terms of publication date, however research published in the last 20 years were given priority. The retrieved data was analyzed thematically to find both analytical and descriptive themes. To further get a better understanding of the context under investigation, desktop analysis was employed using the five steps of the data analysis process: familiarization, thematic framework identification, organizing, mapping process, and interpretation of the results (Crowe et al., 2011). Themes of commonality were discerned, and recommendations were made. 3. Literature review Theoretical perspective Vygotsky's sociocultural theory (1931) served as the foundation for this review of health impact of initiation schools in South Africa. Vygotsky's sociocultural theory is used in conjunction with social constructionism and as a frame to examine the socio-cultural theory. According to Vygotsky and Cole (1978), the development of a person can be comprehended through looking at their own social norms. Each clan is distinct from the others since each has a unique culture. Every clan has an impression of kinship as a result of the principles, standards, and practices, such as initiation schools, because they have meanings associated with them and are how individuals in an ethnic community are recognized. Vygotsky (1931) argues that social behavior occurs in a cultural setting served as the foundation for the sociocultural viewpoint on learning and development. In South Africa, communities believe that initiation signify the change from a particular phase of life to another. Therefore, one can assume that initiation signify a duty to watch over youngsters during their transition from childhood to adulthood. Given this, initiation schools continue to be a significant aspect of most African communities. According to Vygotsky and Cole (1978), the socio-social environment offers the individual a variety of tasks and interacts with actuality using the instruments that are provided. This suggests that involvement in initiation schools and interactions with parents, who serve as the custodians of culture, exert a greater impact on the conceptualizations of the majority of male youngsters. Such custodianships are transferred to caretakers known as "Baditi" throughout the initiation school period, where the initiates are entirely dependent on them. The initiate's operations are initiated by "Baditi" by teaching them what to expect during the process of initiation. The author evaluated the integration of the social constructionism viewpoint in that manner. Therefore, employing sociocultural theory to explore various individual's cultural and social lives helps author get an overview of the things they value and the faith they hold to. In order to comprehend beliefs about culture, the author employed socio-cultural theory to concentrate on the social custom of male initiation school. According to Gergen (1985), Social Constructionism is a theoretical perspective that holds that an individual's existence is a result of cultural and interpersonal interactions. While acknowledging the role of genetically inherited traits, the idea places more of a focus on examining how society has impacted culture and the lives of individuals. The theory of Social Constructionism was chosen as an additional matric theory due to its capacity to generate a collectively formed perspective that serves as the foundation for commonly held views about realities. This additional theory therefore provided the notion that adolescents who receive training in initiation schools acquire expected social behaviors that are required by many society individuals. On the other hand, Carstens (1982) argue that initiation plays a role in the creation of masculinity because it cultivates an aggressive and powerful representation of the man, which serves to maintain and promote maleness. Social constructionism strongly aligns with the ideas of Mfecane (2013), who contends that several masculinities may occur in a particular cultural environment. Mfecane (2013) believes that although it is important to think about how an unequal system is perpetuated by studying members of the group with power, there is a remote possibility of ever overturning the current gender balance without being aware of its flaws and restrictions. Though social constructivists contest this, initiation gives young males authority over women, uninitiated men, and men circumcised at hospitals. Hatfield (2010) challenges culturally accepted notions of masculinity, arguing that they make men be seen as the only competent providers. Men who are portrayed in this way perpetuate discrimination and ignore the abilities of women and marginalized masculinities. Chuene, T.A. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 40 The importance of initiation schools in South Africa The main goal of initiation schools is to help prepare adolescents for the transition from adolescence to adulthood. Numerous cultural groups in South Africa, including the Pedi, Venda, Tsonga, Ndebele, Xhosa, and Basotho perform rituals of initiation with characteristics that are unique in a variety of ways, such as the definition of circumcision, the rituals held prior to and following initiation procedures, the participants in the rites of passage, and the roles they play (AIDS Foundation of South Africa, 2012; Rathebe, 2018). Male initiation rituals are used to emphasize the value of respect for one's own manhood, self-assurance, authentic cultural identification, character development, and acceptance of one's own particular African culture. The social and cultural training provided at initiation schools in respect to the obligations and responsibilities of what it means to be considered a "man" is among the elements considered to be significant. Traditional circumcision is performed for cultural motives as a tradition and a transitional process into manhood (Mdhluli et al., 2021; Makgopa 2005). Cultural understanding of male circumcision in South Africa is to lower the dangers of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This implies that despite the fact that there are additional elements that are more important, circumcision has served as the emphasis in numerous ethnic groups' views on how to "save sex." One of the most important practices that has been scientifically shown to lower the risk of STIs, including HIV/AIDS, human papillomavirus, gonorrhea, syphilis, and herpes, and to name a few, is male circumcision (Dyke & Mathew, 2017). According to research, male circumcision lowers the likelihood of STIs by offering males approximately 60% protection against HIV exposure (Prodger & Kaul, 2017). According to Dyke and Mathew (2017), majority of men and teenagers desire or undergo circumcision for a variety of reasons such as medical factors, sexual reasons, cultural customs, cosmetic considerations, and religious considerations. According to Mdhluli et al. (2021), certain communities no longer practice circumcisions have an interest in adopting it as a method of HIV/AIDS prevention. Leclerc-Madlala (2002) asserts that certain tribal groups now perform circumcision as an HIV preventive measure rather than as a cultural tradition. According to a study by Froneman and Kapp (2017), the customary circumcision of males helps to lower HIV infections. This is supported by Makgopa (2005) who highlighted that circumcision is linked to a lower risk of urinary tract infection, HIV infection, penile cancer, and other STIs. Ndou-Mammbona (2023) asserts that individuals have a chance to use initiation schools for instilling positive behaviours and for effective HIV prevention because the initiates pay attention to everything that is being taught throughout the initiation period. On the contrary, Mutombo et al. (2015) argue that male circumcision cannot completely prevent HIV infection because circumcised men are still susceptible to the virus and can spread it to their partners. Leclerc-Madlala (2002) also disagrees with these assertions and believes that the process may be harmful to one's sexual, emotional, or psychological well-being. Key legislation frameworks and national policies governing South African initiation schools The Children's Act (38 of 2005) was enacted by the parliament in order to give effect to the rights of children as stated in Section 28 of the Constitution (South Africa, 1996). The Act aims to offer legal defence against male circumcision performed without consent. Provisions of the Children's Act emphasize the need to uphold a child's cultural attachments, and the Act's foundational principle is that the child's best interests must be prioritized. As stated in Section 12 (1), all children have the right to be free from religious, cultural, and social customs that are detrimental to their health. Additionally, according to Section 7, a child has the right to be a member of any cultural group they so choose. Section 12 (10) of the Act stipulates that the development phase and maturity of a child must be taken into account while regulating the protection of children's rights in cultural customs, including male circumcision. The Children's Act No. 58 of 2005 appropriately regulates the circumcision of boys under the age of eighteen. Under Chapter 2 of the Children's Act, Section 8(a) forbids circumcision and the application of circumstances that might jeopardize the health of children under the age of sixteen. The Customary Initiation Act No. 2 of 2021, which was recently passed by South Africa, addresses concerns related to the initiation of boys and young men in particular. Registration, permission, restrictions, age and circumcision, discipline and instruction, water, cleanliness, food, healthcare, alcohol and drug usage, and procedures for handling an initiate's death are among the main topics covered in Chapter 4 of the Customary Initiation Act. According to the National Policy on Customary Practice of Initiation, an initiation school needs to be registered in line with its guidelines. Children attending unregistered initiation schools shall be considered abducted and the applicable laws must be upheld in such cases (Department of Cooperative Governance and Traditional Affairs, 2015). In order to accomplish the aforementioned goals, the provincial governments must set up Provincial Initiation Coordinating Committees and the national government, in accordance with the new Customary Initiation Act No. 2, 2021, formed the National Initiation Oversight Committee. These committees' job is to make sure all initiation schools follow the law. The Act states that anybody in charge of any initiation school 41 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 Chuene, T.A. that violates the law by having unregistered staff members and management may face legal action. The Traditional Health Practitioners Act No. 22 of 2007 and the Customary Initiation Act No. 2 of 2021 both permit prosecution of unregistered traditional surgeons. Nowadays, traditional surgeons must register with the appropriate provincial Departments of Health as is mandated by law. According to Chapter 11 of the South African Constitution (1996), a traditional leadership that upholds a traditional legal system and was legally recognized prior to the Constitution's adoption shall remain such authority and continue to fulfill and maintain the rights and responsibilities entrusted to it in line with the rules and regulations in force, subject to any amendments or repeals of those rules and regulations by an appropriate leadership. Legislation controlling traditional circumcision has been passed by a number of provinces. Some examples of legislation from provinces include among others the Limpopo Circumcision Schools Act No. 6 of 2016. In the Free State province there is Initiation Schools Health Act No. 1 of 2004 in place, and the Eastern Cape has the Application of Health Standards in Traditional Circumcision Act. The National Policy on Customary Practice of Initiation in South Africa and the Application of Health Standards in the Traditional Circumcision Act No. 6 of 2001 were anticipated to be in line with these provincial laws. Various provincial laws control the environmental, medical, and social components of the initiation schools. There are additional laws in place to protect traditional leadership's values and to guarantee that it is treated with respect and dignity and such laws include the Traditional Leadership and Governance Framework Amendment Act No. 41 of 2003 which establishes recognizes traditional councils. It also acknowledges the state's obligations to uphold, safeguard, and advance the traditional authority in a way that is consistent with the constitution. 4. Results The results of this review highlight that initiation schools have negative impact on the health and wellbeing of initiates and such impacts are discussed below: Traditional circumcision-related complications at South African initiation schools In South Africa, the practice of traditional circumcision at initiation schools is unfortunately linked to a severe health catastrophe. For example, according to a study by Mdhuli et al. (2021), some of the initiates' health has been compromised due to improper circumcision that resulted in gangrene and septic wounds. These complications are also linked to traditional surgeons' lack of training and expertise, which results in improper surgery. Additionally, according to Banwari (2015), there is a significant likelihood that circumcision performed at initiation schools will result in major negative outcomes, including death. Anike et al. (2013) concurs with Banwari (2015) by highlighting that are higher chance of traditional male circumcision-related complications such as excessive bleeding, gangrenous penis, sepsis, and septicemia, permanent disability from glans or shaft amputation, dehydration, urinary retention, stenosis, fistulae, loss of penile sensitivity, oedema of the glans penis and to the worst-case scenario death of the initiates. As per the Republic of South Africa's Constitution (1996), everyone has the right to life. Therefore, culture cannot take superiority over the right to life. Dehydration is one of the complications that initiates encounter at the initiation schools. Douglas and Maluleke (2018) concluded that during the first two weeks of the initiation process, traditional male circumcision initiates experience dehydration due to restrictions on drinking water and eating certain foods like fruit and vegetables. This is considered as an endurance test as well as a way to minimize frequent urination and weeping of the circumcised wound (Douglas & Maluleke, 2016). Nwanze and Mash (2012) state that initiates receive this kind of training as a way to be resilient, self-disciplined, and strong. Complications from traditional circumcision occur across South African provinces. For example, in Eastern Cape province, thousands of young people have been hospitalized, hundreds have had their penile amputations performed, and hundreds have lost their lives due to traditional circumcision throughout the past 20 years (Kepe, 2010). Douglas et al. (2017) argues that the traditional leaders who are thought to be the guardians of cultural practices and the impacted communities are all gravely impacted by this increase in initiates death rates from the initiation schools. With the majority of the complications ending up in hospitals, the initiation schools' increased number of complications puts pressure on the health system which is already overburdened. For instance, between June 2006 and June 2013, the Eastern Cape Department of Health recorded 5,035 circumcision initiates admitted to hospitals, 453 death cases, and 214 penile amputations (Eastern Cape Statistics, 2013). Traditional male circumcision continues to be recognized in many African tribes as an essential, even sacred, cultural ritual meant to prepare young men for the duties of adulthood. Sadly, a lot of these initiates are exposed to behaviors that have negative health effects. In South Africa, initiation schools for circumcision enroll hundreds of young people annually. Regretfully, certain individuals who undergo traditional circumcision frequently encounter complications that necessitate medical attention (Anike et al., 2013). According to Chuene, T.A. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 42 Moslemi et al. (2011), some complications frequently call for surgery as a solution, which comes at a significant cost to the healthcare budget. Complications including gangrene, septicemia, dehydration, pneumonia, thrombosis, and congestive heart failure are the leading causes of common deaths (Meel, 2010). Another problem is that hospitalization for circumcised initiates is considered culturally inappropriate (Behrens, 2013). Contact with conventional medical hospitals is seen by some as going against the norm. According to Douglas and Maluleke (2018), deaths are a common aspect of initiation schools due to factors such as unfavorable environmental conditions, improper circumcisions, dehydration, unbalanced dietary intake and mistreatment by traditional attendants. Regarding environmental hygiene and the definition of safe and healthy procedures, Rathebe (2018) argue that there is a knowledge gap among the owners of initiation schools. Sithole (2024) reported that the Eastern Cape Department of Co-operative Governance and Traditional Affairs have revealed that at least 34 initiates lost their lives during the 2023 initiation season. The same province saw over 31 deaths during the December 2021 initiation period, which was already more than twice as much as the 14 fatalities from the previous initiation season. Commercialization of initiation schools because of lack of employment The practice of getting circumcised was never intended to be financially profitable. It was customary to give the traditional nurse and the surgeon some of the meat that was killed during the initiation as a thank-you gift. This has evolved through time, becoming increasingly commercialized, with certain individuals now benefiting greatly from the custom. Even well-known and licensed traditional surgeons also referred to as legal traditional surgeons, demand payment from the initiates' families (Douglas & Hongoro, 2018). Traditional male circumcision was only held in the winter and was performed for free of as a community programme by authorities from traditional office. The traditional male circumcision is currently structured looking at the school holidays, making the winter and summer breaks the suitable seasons for new initiates to attend. A profit-driven commercial element has taken control of what had been initially a free service, leading to the establishment of numerous initiation schools under no supervision from traditional authorities (Douglas, 2013). Initiation schools that are not endorsed nor regulated are widely believed to have multiplied. The overwhelming majority of these schools do not follow cultural norms or the customary practice of setting up schools in remote locations far from villages. The findings by Mdhluli et al. (2021) show that initiation schools are susceptible to misuse by opportunistic individuals without employment as well as employed individuals who want to add to their inadequate salaries in order to survive, destroying and weakening a highly respected cultural practice. As a cultural tradition and extra HIV protection measure, traditional circumcision is still performed in initiation schools in South Africa and is still accepted and practiced there. However, to the detriment of this cultural practice, many dishonest organizations or individuals establish initiation schools to further their own economic objectives. Economic troubles and a lack of job opportunities appear to be the primary reason for certain individuals turning to desperate measures to make a living. The founding of initiation schools was once considered sacrilege because it included invoking ancestors. However, some people nowadays overlook the cultural significance and consider it as a chance to make money instead. Therefore, initiation schools are vulnerable to misuse by opportunistic unemployed individuals and some employed individuals who seek to add to their inadequate salaries to survive, weakening and damaging a highly regarded cultural tradition. In South Africa, Indigenous knowledge practitioners continue to undertake and pass down customary procedures including circumcision as initiation (Makgopa, 2005). However, the tradition of circumcision has been criticized and questioned by some individuals as well as media reports. According to reports in the media, there are a lot of unlicensed initiation schools being run by dishonest people who don't respect the sacredness of this cultural rite but are instead only interested in making money. This has several negative health effects, including the eventual death of initiators. But there have been a lot of alarming stories about how unethical professionals are spreading. Problems associated with the circumcision practice in relationship to children’s rights The state is required by the Constitution's section 7(2) to defend, uphold, and fulfil the rights of children. This emphasizes that the state has a constitutional duty to control initiations and safeguard children from potentially life-threatening circumstances. In actuality, though, the Constitution does not ensure that children's interests will be protected. According to section 12(9)(a) of the Act, a child who is above 16 years old may undergo circumcision provided they have given their consent. Additionally, it is explicitly stated in the Act that male children below the age of 16 are not allowed to have circumcision. It is thus argued that, in spite of these clauses, young children are nonetheless coerced into initiation with complete indifference to their rights. There are two exceptions to 43 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 Chuene, T.A. the Act's rules regarding male circumcision under the age of sixteen: religious circumcision and medical circumcision (Section 12(8)). This implies that unless it is done for medical or religious grounds, the Act does not support the circumcision of minors. However, there are societies that promote, coerce, or even hijack children under the age of sixteen to attend initiation. Under Section 12 (10) of the Children's Act, a child has the option to decline circumcision based on their age, developmental phase, and level of understanding. However, most young boys lack the bravery to refuse due to pressure from their peers, societal judgment, as well as individual beliefs (Bosman-Sadie et al., 2010). The inference for parents is that they are breaking the law and breaching their child's rights when they make their kids undergo traditional circumcision without their will. Although there are no consequences for breaking this clause, anyone who does so including physicians runs the risk of being sued for damages under common law by the child who had the treatment done in violation of the Act (Morei, 2017). According to Children's Act Regulation 5(1)(d), cultural circumcision should only be performed by a medical professional or someone who is knowledgeable about the relevant social and cultural customs and has received the necessary training. Comparable regulations apply to religious circumcision, which can be carried out by a physician or a member of the relevant church who has received the necessary training (Children's Act Regulation 6(1)). Nonetheless, circumcision is still performed at random on young children attending initiation schools, some of whom have been abducted. It is argued that the laws and regulations governing initiation schools and circumcision are completely disregarded in some areas. Conflicts between public health standards and initiation practices There are ethical tensions between traditional initiation practices and public health that cannot be overlooked. The regulation of traditional initiation rituals has been the subject of legislation, and most recently, a law governing the safety and well-being of these rituals was passed in South Africa (South Africa, 2018). According to Douglas (2013), operators of initiation schools believe that medical experts frequently impose health regulations and procedures without taking cultural differences into account. They find this to be quite arrogant considering the majority of the healthcare workers who operate in rural regions are black Africans, who are supposed to protect and uphold African culture. Every South African citizen has a right to a healthy, secure, and safe environment, as stated in the country's 1996 constitution. To guarantee that the customary initiation rituals are carried out in secure, healthy, and ethical way, stakeholders should be involved in initiation school practices. In accordance with the law governing initiation schools, the authority given to traditional leaders constitutes one of the groups having the power to address issues relating to initiation ceremonies and initiation schools. These authorities include selecting traditional healers for initiation schools, addressing mistreatment reports, mediating disputes in initiation schools, and creating organizations to defend the rights of initiates. To ensure rational practices in initiation schools, the participation of the following stakeholders is essential: the Department of Health, South African Police Services, the Department of Social Development, and Municipalities. In South Africa, traditional initiation affairs incorporate a variety of stakeholders, but functioning, active involvement and visibility are still required. The health and sanitation at initiation schools are compromised since there will always be a fear of participating fully. According to Douglas and Maluleke (2018), it is challenging to prosecute or detain traditional surgeons who break the rules since the government is never willing to tamper with customs. The necessity for active, aggressive engagement and visibility persists despite the fact that all relevant parties participate in South Africa's traditional initiation rituals. The environment for well-being and sanitation in initiation schools is perpetually compromised by apprehension of participating aggressively. Traditional access rules that prevent different stakeholders from actively participating in initiation schools are the first issue cited by the Commission for the Promotion and Protection of the Rights of Cultural, Religious, and Linguistic Communities. These rules are in place to safeguard traditional revered customs, cultural education, and rites of passage. Unauthorized initiation schools that are not listed on municipal registers present the second challenge. These institutions, which are not acknowledged by the traditional authority, are a major cause of initiate fatalities, as well as pneumonia, dehydration, and genital amputations. Based on the above complications, it is worth arguing that the health of initiates should not be sacrificed in the name of preserving South African cultural beliefs. This conundrum necessitates a drastically altered compliance strategy. 5. Conclusion Although culture is an essential component of African customs that is difficult to replace, children's health and safety come first. Even though South Africa's national and local governments have made significant attempts to Chuene, T.A. GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 44 control the initiation practices and uphold children's rights, significant law enforcement is still required to shield children from unsafe cultural customs. The health of initiates should not be compromised in the name of preserving South African cultural customs. This conundrum necessitates a drastically altered compliance strategy. Even though everyone has the freedom to engage in cultural activities of their preference, cultural rights cannot be exercised in a way that is incompatible with the rights of children. Thus, in accordance with clause 7(2) of the Constitution, the State needs to step in and preserve the safety of initiates. Due to the rise in recorded deaths, catastrophic infections, and unlawful entry into initiation schools, all of which occur within the current legal framework, the authors therefore contend that there is insufficient enforcement of the laws and a lack of public knowledge regarding the impact of initiation on children. The rules and regulations, official standards and codes of conduct that govern initiation and circumcision processes have been disregarded by those operating the initiation schools because there is ineffective law enforcement. In addition to the ineffective execution of existing rules and regulations, the traditional initiation sector is burdened by a lack of direct, continuous, and efficient supervision of the operations of initiation schools. It should be kept in mind that monitoring and assessing the unfavorable practices at these schools is an enormous task because the custom in question is cloaked in secrecy and sacredness. Therefore, legislation alone will not be enough to solve the problems caused by initiation school operations; substantial efforts are required. As a result, this paper suggests the following recommendations: Training workshops for all stakeholders There is still a need for strong, active engagement and transparency in traditional initiation matters, notwithstanding the multiplicity of stakeholders involved in South African traditions. Since initiation schools fall under the jurisdiction of the traditional chiefs and their council(s), providing them with ongoing legal education and training would equip them with the knowledge and abilities necessary to oversee the initiation schools in an efficient and compliant manner. Training workshops aimed at all stakeholders must be held annually prior to the start of the initiation period. By training stakeholders, the intended objectives of successfully governing traditional behaviours are likely to be achieved, as communities are likely to promote these programs if they receive support. In this sense, the government ought to be involved in assisting initiation school programs financially and with training. Active collaboration among stakeholders To preserve the cultural significance and improve the safety of initiates, different stakeholders such as traditional healers, the house of traditional leaders, the traditional surgeons, government officials from national and provincial government departments, such as the Departments of Cooperative Governance and Traditional Affairs, Social Development, Health, and the South African Police Service and local municipalities, members of local Community Policing Forums, the community, and other stakeholders should work together in enforcing the regulations governing the operations of initiation schools. Effective collaboration amongst the stakeholders can help minimize death rates and diseases that can be prevented. It can also guarantee that all necessary services are provided within the initiation schools. In undertaking such initiatives, it is imperative to acknowledge the delicate boundary that exists between the need to guarantee safe healthcare practices and personal freedom to preserve cultural customs. Additionally, this paper also suggest that the Commission for Gender Equality collaborate tightly with other pertinent organizations to guarantee that national and local governments establish the monitoring and oversight mechanisms required to safeguard the rights of initiates, ensuring that they receive the customary practices of circumcision and initiation in safe and secure settings that do not infringe upon their human, sexual, or reproductive health rights. Incorporate initiation processes into the school curricula Everything that is taught at initiation schools ought to be included in the curricula of primary schools, starting with the foundation phase, where life skills are taught. In this sense, teachers who completed the initiation school might be quite helpful. This recommendation aims to rethink the institution's function rather than completely dismantle it, as education and development offer a viable solution. Reflect on the custom In the author's opinion, traditional circumcision is no longer the best option for children due to its complications. Although initiation schools are cultural spaces where young men learn cultural values, rules, adversity, respect, and responsibility, the author believe that their original purpose of shaping men into better members of society has been superseded. Even though the initiation tradition was well-practiced in the past, it is no longer relevant 45 GHMJ (Global Health Management Journal) 2024, Vol. 7, No. 2 Chuene, T.A. in the modern day because there are medical facilities like hospitals and clinics where it may be performed safely. For this reason, the author advises the government to start thinking carefully about the traditional initiation and evaluate its rationale. The purpose of initiation schools is to develop young boys into men rather than being known for causing fatalities and must therefore be carried out in a setting that the children are comfortable with; if not, the custom should be outlawed because it infringes on their rights. Research Research which focuses more on health education for initiates and stakeholders in initiation schools requires immediate attention. The primary areas to focus on should include: hydration quality; the hygienic state of cooking areas; the sterilization techniques used on circumcision instruments; the detrimental impacts of adverse weather conditions on initiates; and the level of compliance with general health and medical care risk waste regulations. Implementation and strengthening of the health promotion programs Provincial houses of traditional leaders should collaborate with municipalities and other stakeholders, particularly parents, teachers, and school administrators, to carry out successful community education awareness campaigns. The author suggests that to reach the full participation of the community and prevent health-related issues, those planning programs on health promotion must be attentive to the cultural traditions linked with initiation schools. Thus, the results of this study support Douglas's (2013) recommendation to put the developed health promotion program into action. The success of health promotion programs can be achieved through collaboration with skilled circumcision practitioners under the guidance of health promotion practitioners who are culturally orientated. 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