The much-anticipated annual Child Gauge report was launched earlier this week. The report, compiled by the Children’s Institute of the University of Cape Town, puts the state of children’s rights in focus and highlights the need for a number of key interventions.
The theme for this year’s Child Gauge, “Child and adolescent health: Leave no one behind”, is the first health-focussed edition of the Gauge in 10 years. Children’s health is discussed in relation to the first 1 000 days of a child’s life, the Sustainable Development Goals as well as contemporary social, political and environmental issues.
The Gauge offers a unique perspective on health, going beyond the clinical science to interrogate a wide variety of factors that can impact a child’s life. The report seeks to pinpoint how South Africa can take the next step in child and adolescent health from just surviving, to surviving and thriving.
Child health in focus
“Child and adolescent health is such a critical issue.”, Lori Lake, one of the Gauge’s editors told Spotlight. “There are a whole range of policy developments on the table that need to be addressed. We’ve also tried to fill the book with a range of case studies that showcase the best practise on the ground. What we’re hoping to do is not only create a resource for policy and decision makers in civil society, but really to stimulate change in every level of the healthcare system.”
Lake said that one of the biggest successes in South African child health was the significant reduction in the under-five mortality rate. “We’ve seen a decline from 79 deaths per every 1 000 live births, to 32 deaths per 1 000 live births in 2018, and that’s a powerful shift from where we were 10 years ago,” she said.
While the decline in the under-five mortality rate is celebrated, the Gauge states that children continue to die from preventable conditions.
According to the report South Africa’s performance is far behind other middle-income countries like Cuba and Brazil. “There’s a concern that we are not achieving our potential,” said Lake.
Lake highlighted neonatal mortality as a critical concern and said it accounts for a third of under-five child deaths.
“We are seeing little or no progress over the last 10 to 15 years. There’s a real concern about the vulnerability of newborn babies, and we need to work hard not just in neonatal care, but we need to look upstream.”
The Gauge states that few women are managing to access care during the first 20 weeks of pregnancy, and that only 32% of newborns are breastfed throughout the entire first six months.
Among the hard-hitting facts in the Gauge is that 1 out of every 31 children in South Africa die before their fifth birthday. “That means that 30 children (out of 31) are surviving,” Lake emphasised. “And there are concerns around the extent to which we are enabling those children to thrive and reach their full potential.”
“Everyone can champion child health,” said lake. (Read more about a child’s first 1 000 days here.)
NCDs and social determinants of health
The threat of non-communicable diseases in mothers, children and adolescents was another focus area in this year’s Gauge - taking into consideration the impact of nutrition, access to safe water, stress in the home and violence.
“It’s about changing the social determinants of health,” Lake said.
According to the Gauge 27% of children are stunted as a result of malnutrition.
“Equally there’s a concern around obesity,” Lake noted. “Thirteen percent of young children are obese, but a child who is obese at the age of 5 is five times more likely to be obese by the time they reach adulthood.”
“There’s something about the food environment and the food industry that is driving this obesity epidemic in South Africa. Similarly, we’re looking at the introduction of vaping, which is marketed as a way for adults to smoke less, but if you look at the different brands you’ll see they are actually targeted at children.”
Lake stated that this focus on industry as a third-player in child and adolescent health, alongside government and families, was a game changer and require urgent government and civic intervention.
Other statistics in the Gauge include: 60% of children live in poor households, 30% do not have access to water on site, 18% are in overcrowded households and 1 in 10 children live in informal housing. All of these factors put children at risk of environmental health hazards and violence, said Lake.
Michael Hendricks, another editor of the Gauge said that children were particularly vulnerable to a harmful environment.
“It’s essential that environmental health is explicitly addressed in policies. Children are not visible in a lot of environmental policies and this is in conflict with their rights – [their] right to know and comprehend, to a safe environment and to participate,” he said.
The first part of the Gauge specifically considers various social and environmental policies that impact child and adolescent health. This includes the Draft Control of Tobacco Products and Electronic Delivery Systems Bill, the Draft Control of Marketing of Alcoholic Beverages Bill, the Carbon Tax Act, the Draft Climate Change Bill and the National Health Insurance (NHI) Bill.
A place for child health in the NHI
While the NHI Bill recognises children’s basic right to health services, the Gauge remains concerned over inadequate representation from the child health sector.
“What’s of concern is that 20 years since we adopted the Constitution the state still hasn’t defined what basic healthcare services for children actually mean. That means that children and families are unsure of what they’re entitled to, and it makes it very difficult to know whether child and adolescent health is being adequately resourced,” said Lake.
She said an additional concern with the current bill was the lack of representation from the child health sector in the Benefits Advisory Committee, which was tasked with defining a series of baskets of care and essential medicines list.
“There’s real concern that efforts to try and promote efficiency will result in a really narrow basket of care for children. Without adequate representation in the process, children will be short-changed in the NHI,” she said.
Another aspect of NHI that is of particular interest for children and adolescents is the re-engineering of the primary healthcare system. “We’ve been very excited about it,” said Lake. “Particularly about the introduction of a series of teams that should be focused on child health.”
These teams could include ward-based outreach teams, community health workers, school health teams, and the introduction of district clinical specialist teams (DCST). Lake stated that the DCST would play an integral part in navigating inter-sectoral collaboration on child and adolescent health with other government departments including Social Development and Basic Education.
However, concern is expressed in the Gauge that there is no mention of the DCST in the current NHI Bill.
The Gauge is also critical about the required documentation for children in order to be registered. The report suggests that the requirements for user registration could worsen the equity gap, particularly in rural areas.
The Gauge flagged the lack of the Office of Health Standards and Compliance (OHSC) accredited facilities as another concern. In the OHSC’s most recent audit of facilities in the 2016/17 financial year, only 5 out of 696 were up to standard. This could mean that rural patients won’t have access to accredited NHI facilities.
Child-friendly health services
According to the Gauge, South Africa still has a long way to go towards making healthcare services child-friendly.
Lake highlighted that some attempts had been made such as keeping clinics open after school hours and staffing younger nurses, but there has not yet been a closer look at what is really needed to improve services.
“If we look at child health from a child rights perspective one of the key transformations that’s needed is for children to be treated like human beings, and to be treated with dignity, care and respect,” said Lake.
From the age of 12, children in South Africa can give medical consent. In the Gauge it is argued that for children to give informed consent, they must fully understand and have access to information about treatment in child-friendly language.
HIV and adolescent health
While the rate of HIV infections has dropped by 44% since 2012, adolescents continue to be the most at risk. The Gauge states that young adults (15 – 24 years) accounted for over a third (38%) of new infections in 2017, and that HIV incidence was highest among young women, stating that they were three times more likely to become infected than young men.
The report estimated that there were 66 000 new infections in young women compared to 22 000 in young men in 2017.
While South Africa has made great strides in ensuring access to ARV treatment, access to adolescent-friendly health services continues to be a challenge.
The Gauge states that in 1999, South Africa launched the National Adolescent Friendly Clinic Initiative (NAFCI) which rolled out a set of national standards to improve the quality of adolescent-friendly health services. After the implementation, NAFCI clinics performed considerably better than control clinics, and an Ideal Clinic Initiative began. Part of the initiative includes a checklist designed to measure progress towards improving health facilities for adolescents.
While the checklist serves as a good foundation for improvement, navigating treatment for adolescents with communicable or chronic illness remains tricky. The report suggests a collaborative approach between sectors to help monitor and treat adolescents with long-term health conditions.
Lesley Bamford from the National Department of Health’s Child and Youth Directorate said that the reduction in the under-five mortality rate was significant, but that a further reduction of 22% was needed in order to meet the 2030 Sustainable Development Goals. “Our department recognises the first 1000 days and adolescence as critical periods for intervention.” She called on civil society and government to work together to ensure that vulnerable children receive a comprehensive package of services.
Bamford reiterated the importance of the NHI Bill, adolescent health services as well as combating gender-based violence. “Gender-based violence has been flagged as a pervasive problem and society needs to work together. As a department we have services to support women who have experienced gender-based violence. We need to work closely with young people,” she said.
*The South African Child Gauge 2019 can be accessed online here.
This article was produced by Spotlight – health journalism in the public interest.