On November 30 this year we celebrated the 30th anniversary of the signing of the United Nations Convention on the Rights of the Child (CRC). Today, International Human Rights Day, recalls the signing of the Universal Declaration of Human Rights, and is another opportunity to remind ourselves of children’s legal entitlements in order to promote children’s optimal health, survival and development.

The right to health is defined broadly in international law: The CRC guarantees children’s right to the “highest attainable standard of health”, which extends beyond the absence of illness and injury to include a “state of complete physical, emotional and social well-being”. And it is this vision of children not only surviving, but thriving and reaching their potential, that should guide our vision for child health in South Africa.

Survive

Over the past 10 years, South Africa has made dramatic progress in reducing under-five mortality from a high of 79 deaths per 1,000 live births in 2004 to 32 deaths per 1,000 in 2017.

These gains have been driven primarily by the prevention of mother-to-child transmission of HIV, yet South Africa’s under-five mortality rates remain high compared to other middle-income countries such as Brazil (14) and Cuba (5), and many young children continue to die from preventable causes such as neonatal conditions, HIV, diarrhoea, pneumonia and injuries. There are also significant differences between more urban and rural provinces – with the young children in KZN more than three times more likely to die before their fifth birthday than those in the Western Cape.

Greater efforts are therefore needed to improve the survival of young children and adolescents, especially neonates, who are particularly vulnerable and account for a third of deaths among young children.

Thrive

As mortality rates decline, South Africa needs to intensify efforts to promote children’s optimal health, growth and development, and prevent childhood illness and injury – including as a result of HIV, violence, mental health conditions, malnutrition and long-term health conditions.

The number of new HIV infections in children dropped from 42,000 in 2008 to 14,000 in 2018, driven by the successful prevention of mother-to-child transmission of HIV. Yet 28% of pregnant women are HIV- positive. This raises concerns about the 21% of children who are uninfected yet HIV exposed. These HIV-exposed uninfected children, if not cared for appropriately, may be at higher risk of death, prematurity, poor growth, recurrent acute and chronic respiratory illness and poor neurodevelopmental outcomes.

Greater investment is therefore needed in prevention programmes to address the drivers of HIV infection among young women and adolescent girls, as young people (15-24 years) account for over a third (38%) of all new infections, and young women (15-24) are three times more likely to become infected than young men.

Violence against children is pervasive: For example, 99% of children in Soweto-Johannesburg had either experienced or witnessed some form of violence, with more than 40% of children reporting multiple exposures to violence in their homes, schools and communities.

Mental health is also of concern as 50% of mental health problems are established by the age of 14 years. Globally, an estimated 10-20% of adolescents experience mental health conditions such as depression, anxiety and alcohol use disorders, and suicide is the third leading cause of death in older adolescents (15-19 years old).

Malnutrition further compromises children’s health and development – 27% of young children are stunted and 13% are overweight or obese – and is driving a growing burden of non-communicable diseases such as cancer, heart disease and diabetes in adulthood.

An estimated one in five children have a disability or long-term health condition that requires early intervention and complex care across the life course in order to ensure optimal functioning and participation in family and community life.

Transform

While health sector reform is indeed necessary, it is not sufficient to address the burden of childhood morbidity and mortality. Proactive engagement with other sectors is also needed to address the social and environmental determinants of child and adolescent health.

South Africa’s children remain disproportionately affected by poverty – with nearly 60% of children living below the upper-bound poverty line (that is, in households with a per capita income of less than R1,183 a month in 2018). Poverty has a profound impact on children’s living conditions and access to services, and undermines families’ capacity to provide and care for children. For example, children living in poor households are less likely to have access to safe water and sanitation on site, are more likely to experience hunger and overcrowding, and more likely to travel far to reach health care services.

A growing body of evidence from a range of disciplines including economics, neuroscience and epigenetics, highlights how early exposure to adversity compromises children’s lifelong health and development – including their education and employment prospects. It is therefore vital to intervene early – during the first 1,000 days of life and again in adolescence – when children are most sensitive to their environments and investments are likely to yield the greatest returns.

Children’s rights provide a powerful framework for promoting children’s optimal health, survival and development. A child rights approach encourages us to adopt an expansive view of health that extends beyond children’s right to healthcare services to include their constitutional rights to sufficient food and water, access to housing, protection and an environment that is not harmful to health. These rights apply to all children without discrimination, and require the state and other duty bearers to actively consider children’s views, take them seriously and act in children’s best interests – so that services are more attuned and responsive to children’s needs.

So, what then are the implications for health care services?

First, we need to prioritise child and adolescent health and put children at the heart of the healthcare system.

Second, we need to develop an essential package of care that gives effect to children’s immediately realisable constitutional right to “basic health care services”. This package needs to extend beyond medical treatment and include investments in health promotion, prevention, early intervention, rehabilitation and palliative care – extending from conception through to adolescence – and addressing the needs of the one in five children with long-term health conditions. This essential package must be accompanied by norms and standards for child-friendly equipment, medicines, staff and infrastructure, in order to build a child- and adolescent-friendly healthcare service and ensure that children receive their fair share of resources.

Third, we need to give effect to the rights of children within the healthcare system. This includes their rights to dignity, their right to information about their condition and treatment options, and their right to participate in healthcare decision-making. This requires a fundamental shift in the way in which health professionals engage with children and families – from telling to listening – in order to better understand their signs and symptoms, address their fears and concerns, and include children and families as active partners in health care.

Fourth, we need to strengthen referral systems and community-based services in order to ensure continuity of care, and to bring healthcare services close to home – especially for vulnerable children such as new-born babies, those living in deep rural areas, and children with disabilities and long terms health conditions.

Fifth, health workers need to step outside their facilities in order to better understand the context in which children live. They need to take the lead in building local networks of care and activate support across a range of sectors in order to address the complex needs of children and families – responding to local risks, but also actively building on existing strengths within the family and community.

Finally, we need child-centred data in order to make children visible, and to enable us to identify, target and support those left furthest behind.

Over the past 10 years, South Africa has indeed made good progress, yet it is clear much work remains to be done. Strong leadership and champions of children will be needed at all levels of the healthcare system in order to close the gaps and ensure that all South Africa’s children are able to thrive. MC

Lori Lake is an editor of the South African Child Gauge 2019 which is published by the Children’s Institute, University of Cape Town in partnership with the DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand; Unicef South Africa; the Standard Bank Tutuwa Community Foundation and the Desmond and Leah Tutu Legacy Foundation.