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Medical experts in plea to exempt child health services from budget cuts

More than 100 doctors, healthcare workers, academics and child advocacy groups have released a joint statement addressed to government, raising the alarm about the impact of austerity and budget cuts on the lives of South Africa’s poorest children.

The statement by the Child Health Priorities Association is unusual and important, the Daily Maverick says, because its signatories include every one of the major child advocacy organisations in South Africa; academics and paediatric departments of five South African universities, and more than 100 professors, doctors and other allied health workers with an interest in child health and well-being.

Its authors say it was necessitated by growing evidence of the harm to children caused by Covid-19, unemployment and violence (among other things).

Experts say a malnutrition epidemic is growing and will have an impact on the life outcomes of children for generations to come.

Similarly, child health and social services are stretched beyond breaking point at a terrible cost to children.

The signatories point out that in the context of the Constitution promising “all children” the right to “basic nutrition, shelter, basic healthcare services, and social services”, the government should be increasing and improving child welfare services, rather than undermining them.

Statement

According to Statistics South Africa, one in every three people in South Africa is under 18.

If we, as South Africans, make the right investments to promote their optimal health and development, our young population has the potential to transform our country and drive social and economic development.

Yet, as explained in the Advocacy Brief by the Children’s Institute at UCT, our youngest citizens are disproportionately concentrated in the poorest households, highly vulnerable to shocks such as the Covid-19 pandemic and the economic recession.

At the Child Health Priorities Conference, hosted at the University of the Witwatersrand in November 2022, we noted with concern Treasury’s intention to cut social spending, as outlined in its October 2022 Medium Term Budget Policy Statement. This includes cuts to health care services and social assistance. These cuts threaten to undermine the provision of essential child health services, pushing more children even deeper into poverty.

A call to action

The UN Committee on the Rights of the Child has issued clear guidance that States should not introduce retrogressive measures such as austerity budgets that compromise children’s rights to health, survival and development.

We therefore call on health professionals, managers and administrators at every level of the healthcare system to take proactive steps to safeguard and ring-fence budgets for child health services to ensure the proposed austerity measures do not introduce retrogressive measures or erode children’s rights to healthcare services.

We draw on the latest science, economic and legal arguments to support the call for the protection and ring fencing of budgets for child health services.

(1) Children’s health and access to healthcare services are already compromised

• Even before the pandemic, there is evidence from the Medical Research Council and Department of Health that many South African children were failing to thrive with more than a quarter of children under five years old stunted in their growth and development;

• The Covid-19 pandemic orphaned nearly 150 000 children while the accompanying recession pushed a further 1.5m children into food poverty – so that by 2020, four in every 10 children lived in households that could not afford to meet their children’s nutritional needs (Hall K. Poverty, unemployment and social grants. In: Tomlinson M, Kleintjes S & Lake L (eds) South African Child Gauge 2021/22.);

• Post-Covid, rising food and fuel prices have further eroded children’s food security, nutritional status, and access to healthcare services;

• The reduced utilisation of routine primary healthcare services seen at the start of the Covid-19 pandemic has persisted and is associated with low immunisation coverage as evidenced by the recent outbreaks of preventable diseases such as measles and whooping cough.

(2) The science

There is now incontrovertible evidence that early life experiences fundamentally determine the developmental origins and trajectories of health or disease across the life course, and across generations. With this knowledge, there is a growing recognition that it is most effective – and cost-effective – to intervene early in life to prevent illness and promote optimal health and development.

For example:
• Published research has shown that 50% of mental disorders have their onset before the age of 14 years, and 75% before the age of 24 years, and prevention and early intervention in childhood and adolescence were identified as “the most promising investment in population mental health” by the Lancet Commission on Global Mental Health;

• Similarly, the “slow violence” of the triple burden of child malnutrition (under-nutrition, obesity, micronutrient deficiencies) is fuelling the acceleration of non-communicable diseases that threatens to overwhelm the healthcare system.

In both cases, it is more effective – and cost-effective – to invest in prevention and early intervention, even preconception, where efforts to ensure the health and well-being of adolescents before childbearing has the potential to kick-start a positive intergenerational cycle of human capital development.

(3) The economic arguments

These investments in child and adolescent health will reap a triple dividend –for the children of today, for the adults they will become tomorrow, but also for the next generation of children.  For example, a recent systemic review (Long-term economic outcomes for interventions in early childhood: protocol for a systematic review. BMJ Open 2020) noted that:

“Investment in early childhood generates positive returns, for the child, the family and the wider community. Benefits to children in the short term include the development of resilience, improved cognitive skills, reduced school absenteeism and reduced risk of disease. Longer term outcomes include better employment pathways, improved health, reduced dependency on welfare (including social services, incarceration and juvenile justice) and reduced inequality.

“This is particularly true for children unable to fulfill their full potential, due to poor health, lack of opportunities to learn and/or deprivation of care. Improving early child development has the potential to improve national productivity and gross domestic product. It is not simply a ‘nice to have’ in an ideal world. Conversely, the cost of failing to adequately support children has implications for the child, community and the national economy.”

While interventions initiated in the first 1 000 days of life have been shown to yield the highest economic returns, particularly for children experiencing adversity; these investments need to be sustained throughout childhood into adolescence to ensure the benefits are not eroded over time.

The second decade of life is a time of risk, but this period of rapid development also offers another opportunity to enhance outcomes and set the trajectory for lifelong health and development. Interventions to support adolescents’ physical, mental and sexual health during this period have been shown to yield up to a 10-fold return on investment by saving lives and reducing unintended pregnancies.

(4) Global commitments and evidence-based guidelines

The emerging science and economic arguments have informed a shift in global health strategy from a narrow focus on survival to a broader thrive agenda – as outlined in the Global Strategy for Women’s, Adolescents’ and Children’s Health, the Nurturing Care FrameworkGlobal Accelerated Action for Adolescents, and the World Health Organization’s quality standards for maternal, newborn and paediatric services to ensure access to safe, effective, quality and affordable care.

(5) The legal arguments

Section 28 of our Constitution recognises children’s vulnerability and the State’s obligation to uphold their best interests and provide a higher standard of care and protection. For this reason, children’s right to basic health care services is immediately realisable and is not subject to progressive realisation or limited by available resources.

The state is therefore obliged to put in place definitive measures to give effect to children’s right to health care services. This includes adopting appropriate laws, policies and programmes; providing the necessary budget and resources; ensuring the design and delivery of health care services upholds ‘children’s best interests; and improving child health outcomes across a range of indicators.

In addition, Article 24 (2) of the United Nations Convention of the Rights of the Child states that government must prioritise child health within the health plan for the general population, and in its General Comment 14 on the right to the highest attainable standard of health the UN Committee on Economic, Social and Cultural Rights stipulates that these health goods, services and programmes should be available, accessible, acceptable and of good quality.

No retrogressive measures

In 2020, the Gauteng High Court (in Equal Education and others v Minister of Basic Education and others (17 July 2020), a ruling against the closure of the National School Nutrition Programme) noted that once a state has taken on such an obligation, it cannot “back-track”.

The High Court then affirmed the United Nations Committee on the Rights of the Child’s General Comment 19 on Public Budgeting for Children’s Rights which stipulates that states “should not take deliberate regressive measures in relation to socio-economic rights” and that even in times of economic crisis, “regressive measures may only be considered after assessing all other options and ensuring that children are the last to be affected, especially those in vulnerable situations”:

“State parties shall demonstrate that such measures are necessary, reasonable, proportionate, non-discriminatory and temporary and that any rights thus affected will be restored as soon as possible. States parties should take appropriate measures so that the groups of children who are affected, and others with knowledge about those children’s situation, participate in the decision-making process related to such measures. The immediate and minimum core obligations imposed by children’s rights shall not be compromised by any retrogressive measures, even in times of economic crisis.”

In conclusion

While we recognise that resources are constrained, but budget cuts should never be made at the expense of child health. All too often child health services are cut because children have no voice, while civil servant salaries and parliamentary perks remain untouched. Cutting child health services and social assistance in the context of rising poverty and hunger, constitutes a clear violation of children’s rights and a shameful betrayal of the very central pillar of our Constitution.

The child’s name is Today
The child cannot wait.
Right now is the time the child’s bones are being formed,
blood is being made, senses are being developed.
To the child we cannot answer “tomorrow”
The child’s name is Today.

(Gabriela Mistral, Nobel Prize-winning poet from Chile)

Issued by the Child Health Priorities Association Executive Committee

Advocacy Brief_Overarching_02_08

The Lancet Commission on global mental health and sustainable development (Open access)

 

The BMJ article – Long-term economic outcomes for interventions in early childhood: protocol for a systematic review (Creative Commons Licence)

 

SAFLII court case (Open access)

 

Daily Maverick article – Advocates call for child health services to be protected from from austerity cuts (Open access)

 

See more from MedicalBrief archives:

 

Time to take the reins from politicians to fix SA’s health crisis

 

‘Rage and grief’ as children die of malnutrition, while govt punts NHI that’s likely to fail

 

UFS: Child malnutrition – human rights violation and slow violence against children

 

Government slashes already under-funded health budget

 

‘Heartbreaking’: South Africa has more than 134,000 orphans from COVID-19

 

 

 

 

 

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