CONTRIBUTIONS TO THE GENERAL COMMENT ON THE RIGHT OF THE CHILD TO ENJOY THE HIGHEST LEVEL OF HEALTH (ARTICLE 24) CRC

AUTHORS:
Latin American Group for Health and Children's Rights,(“Southern Cone Initiative”) consisting of health professionals and related professions of Argentina, Colombia, Chile, Paraguay, Dominican Republic and Uruguay. Participants: Ernesto Durán (Universidad Nacional, Colombia), Javier (ColombianSociety of Pediatrics), Helia Molina (PUC, Chile )Irene Melamed () and Raúl Mercer (FLACSO, Argentina),

Contact: Raul Mercer FLACSO (Latin American School of Social Sciences, Argentina)

Child Rights Education for Professional-CRED-PRO-International Institute for Child Rights and Development-IICRD-The University of Victoria, Canada.

Contact: Gary Robinson .

Society for Equity and Child Health (SECH, U.S)

Contact:Jeffrey , University of Florida, Department of Pediatrics,

COLLABORATORS: (*Members of the Southern Cone Initiative):

Villamizar, Hernando*.President, American Association of
SanabriaMoudelle, Claudia*. Health Department of Children and Youth, Ministry of Public Health and Welfare - Paraguay.

Mayorga, Clemencia*.ColombianSociety of .

Rubio Mesa, MariaLucia*. Assistant Professor. School of Medicine.Pontificia Universidad Javeriana. Bogota, Colombia.
Posada AlvaroDiaz. Colombian Society of Pediatrics. Medellín. Colombia
Leyton Barbara Cardenas* National Health Program in Childhood Life Cycle DIPRECE Department / Secretariat of Public Health, Ministry of Health, Chile
Moreno Lopez Janneth Diva, Adolescent Health Program, Bogotá, Colombia
Tejeda P, Altagracia M*. National Health Advisory Plan International Dominican Republic
Michelini, Maria Laura* Uruguayan Society of Pediatrics
Schön, Andrea*, National Pediatric Hospital Juan P. Garrahan, Buenos Aires, Argentina,
Hammermüller, Erica*, Children's Rights Group, Argentine Society of Pediatrics,
Cordero, Miguel*,nistry of Health, Santiago, Chile.
Bedregal, Paula*. Associate Professor, School of Medicine, P. Catholic University of Chile. Santiago, Chile,
Fernandez-Jacomet, Susana*.FLACSO Latin American School of Social Sciences, Buenos Aires,
Nereyda Catalan, Concha*. Past President of Chilean Society of Pediatrics, Adjunct Associate Professor of Pediatrics at Pontificia Universidad Católica de Chile,
Esquivel, Ida Liedtke*. Coordinator, Committee for Social Pediatrics, Paraguayan Society of Pediatrics
González Fernández, Luis Felipe*, Director Chilean Society of Pediatrics,
Gorodisch, Ricardo, Kaleidos Foundation, Buenos Aires, Argentina,
Llobet ,Valeria, Equity for Children (
Fabbiani, Andrea, Ministry of Public Health, Uruguay.
Norato, Ximena, Director, Bureau of Communications, Journalism ally of children, social development and research-Pandi-Colombia

RESPONSE TO SUGGESTED QUESTIONS

1. Basic premises about the right to health and guiding principles (Questions 1 and 2):

The right to health includes both the right to maintain health and the right to restore health. This right applies to both individual health and collective health (public health). To ensure the right to maintain and restore health States must take positive action. These include health promotion policies, universal provision of services, legislative and policy measures to promote equity and universal access to health.
Health is a social good which implies the possibility of enjoying well-being and quality of life that is greater than the presence of any health condition or disease. Health is a social construct and does not depend on any one person or any one sector of society. The health sector is an actor in ensuring the right to health, but it alsobecomes importantto be nearchildrenand familiesfrom pregnancyto the early years.

Guaranteeing children the right to health includes State actions on the determinants of health across the life span (which is applicable to children's health act pre-conceptional period and during pregnancy). The State shall guarantee equal access to all the basic determinants of health (save and balanced diet, nutrition and quality housing provided with essential public services, decent work for parents, basic sanitation, including water, healthy environment,-also includes polluting effect of industries, pesticides, mining-,education, clothing and access to appropriate health services).

The right to health is closely linked not only to the right to life but to the right to a quality of life, which means creating conditions that will ensure children and adolescents with an adequate standard of living for the development of their optimal potential in their adult lives.

The right to health is interdependent with other rights. Thus, health depends on the effective guarantee of other rights and is a fundamental enabling factor for the exercise of these other rights. Guaranteeing the right to health is indivisible from the security of all other rights for children and adolescents. Although Article 24 expressly refers to the right to health, the text of the Convention deals with matters relating to the right to comprehensive health care, specifically Articles 6, 12, 17, 18, 19, 20, 23, 24, 26, 27, 28, 29, 31, 32, 34, 36 and 42.

The health of children and adolescents is a fundamental right that cannot be restricted or limited by national legislation, state or local, or subject to economic constraints. States should use their legal and political authority to recognize the universal right to health.

The best interest of the child should be the guiding principle that guides all States’ decisions about health of children and adolescents.

The principle of universality provides that States should ensure that policies, programs, plans, and strategies aimed at both preserving and restoring health through universal coverage without discrimination of any kind. For each of the services and of health promotion and prevention activities, four basic conditions should prevail: availability, accessibility, acceptability and quality. In order to ensure the universality of health there must be equity in access to health care and to the underlying determinants of health throughout the State

States should ensure that respect for the right to health is continually progressing. This means that more and more services are incorporated into health plans and the plan’s promotion, prevention, treatment and rehabilitation activities. No State can be regressive in its guarantee of the right to health, nor may any service be withdrawn, unless it has proven useless or potentially harmful. If the State has delegated the provision of services to private actors the state should ensure that they comply with this principle.

Children and adolescents and their families have the right to participate actively in decisions affecting their health in any way and their opinion should be taken into account with respect to these decisions.

2. Obligations and responsibilities derived from Article 24

Article 24 establishes the obligation of States to make every effort to promote and safeguard the health of all children and adolescents, and to ensure treatment and rehabilitation of patients. They should include: public health policies that promote positive impact (and discourage any negative impact) on child health through each public policy, ensure universal health services, primary health care, combat malnutrition and disease, ensure clean water and unpolluted environments, ensure timely and appropriate pre-and postnatal care, and provide information and health education to children, teens, parents and community.
States have the obligation to respect, ensure and protect the right to health, which include: not advancing or promoting policies or actions (by any sector of the State) that adversely affect in any way the health of children; provide resources and the means necessary to achieve the guaranteed right to health; ensure through policies, plans, programs, strategies and actions of both the health sector and other sectors involved in the promotion and care of child health; protect children and adolescents against any situation that violates or affects their right to health by any member of society or the state itself; prevent discrimination and adopt legislative means and differentiating political actions for the most vulnerable groups; monitor compliance with its obligations of the other actors who share responsibility for child health: the family and society and immediately restore rights when violations have occurred; discourage and punish violations of the right to individual or collective health, committed by public servants, or by any citizen, company or institution.

States should have universal coverage policies aimed at caring for, preserving and promoting child health, preventing disease (which includes early detection of risks and acting on them), providing adequate and timely care and rehabilitation of all children, and adolescents who need care.

Since there are major social and economic inequalities that significantly affect the health of poor children and adolescents, States must prioritize health care for the most vulnerable and marginalized populations. This means ensuring social inclusion of all children and adolescents, regardless of their health condition, disability, cultural, religious, gender, socioeconomic status and age.

The promotion and prevention activities aimed at children and adolescents should be directed to:
• Promote and ensure all rights and specifically the rights to life, the quality of life, healthy environment and the preservation of health.
• Promote health and growth and harmonious development.
• Promote self-care and health care by parents and caregivers.
• Identify protective factors and risk factors, increase the former first and control the latter.
• Promote humane rearing practices, good treatment and bonding.
• Promote knowledge, ownership and exercise of sexual and reproductive rights by children and adolescents.
• Promote healthy lifestyles.
• Encourage breastfeeding, complementary feeding, balanced and healthy eating for all ages.
• Prevent illness and health problems, accidents and problems in growth and development.
• Identify and intervene early when there are physical, mental, emotional and sensory changes.
• Promote community participation and coordination with other sectors to promote overall health.
• Establish and monitor the conditions of health, growth and development of each child or adolescent.
States should guarantee the right to permanent adequate nutrition (balanced, comprehensive and quality), and adequate livable conditions for all children and adolescents without exception.

The care of children and young patients should be comprehensive, timely, high quality and with warmth. Such care should be directed to the speedy recovery of the highest attainable standard of health and the prevention of any kind of relapse or injury. Health care facilities must be geographically and culturally accessible for the entire population, without cost barriers that impede access. The care of children and adolescents should be a priority within health systems.

All health services and activities aimed at children and adolescents should be conducted in a holistic framework of respect for their dignity and rights, which means respecting their autonomy, respect for their privacy, respect for the right to remain with their family (they should not be separated from their family when they are admitted to health facilities), respect their right to participate and comment so that their views are taken into account, their right to information, their right to education and recreation and the right to be protected from maltreatment, abuse, neglect and any form of exploitation.

States should provide the maximum possible resources to ensure the right to health by children and adolescents. This means that the percentage of the budget for this purpose should never decrease and should increase progressively, as the social and economic development of each State allows.
States must ensure timely and non-discrimination to all children and adolescents who have some degree of permanent limitation (whether physical, cognitive, mental, sensory or otherwise) or a chronic disease with significant impact to their health. They should have available rehabilitation services deemed necessary to enjoy a dignified life in conditions of equality with others, and to help them reach their full potential and participate actively in the community. States should eliminate any barriers to accessing health services for these children and adolescents.

3) Priority concerns in Latin America

The trend of the processes of health sector reform that have occurred in Latin America have affected the different countries of the region in different ways. In some cases it has privatized the management and delivery of health services, making them a good, limited rights provisions in an established contract, and deepened social inequities and limited nutritional health. The loss of the role of stewardship of health by the States has generated disturbing corruption in the sector, with emergence of power groups with great influence over the priorities, policies and actions on health.

As a consequence of the above, there has been a worrying fragmentation of health services. Health is not considered as an integral theme today, but rather, one that is divided into different market niches, each of which has its own particular interests.It is the obligation of States to have comprehensive policies that are designed and implemented across sectors and that child health should be in all of these policies
Financial groups see the health sector as a business. As such they have monopolized the market for vaccines, drugs and diagnostic and therapeutic support, leading to high costs that are not accessible to most third world population. These private groups do not prioritize the most common diseases of childhood and adolescence in their research, because high-cost chronic diseases are more profitable. The free trade agreements have strengthened this scheme by promoting respect for product patents essential for child health.

States’ investment in priority areas such as safety, rescuing the financial sector or external debt payments, leaving child health and nutrition as a low priority investment.

Great social and economic inequities have generated health inequities and resulted in a condition where most of the deaths of people under 18 are from health problems that are preventable. Poverty, malnutrition, lack of access to basic services, inadequate housing, and unsanitary environments are the background to most health problems in the population under 18 years of age. National averages hide large inequalities in health within countries.

These inequities in health rather than be addressed by services provided by the State, often are increased by new inequities in access and quality of health services and nutrition.

Although primary care has improved, it is limited in coverage, quality and timeliness. This has generated a condition where most of the States’ resources are invested in addressing health problems that could have been prevented. There are many primary care strategies that have been implemented in the region that have an impact on child health (IAMI-IAFI, IMCI, Healthy Kindergartens, Healthy Schools, sexual and reproductive health, adolescent-friendly services, etc..), These strategies do not currently receive sufficient support from the States to turn the tide of inequitable health.

Concern in the region is focused on the problems of malnutrition, anemia, micronutrient deficiencies, overweight and obesity, low birth weight, congenital problems, perinatal problems, morbidity and mortality from acute respiratory illness and acute diarrheal disease, oral problems, problems in development, limitations and disabilities, mental health problems, accidents, violent deaths, maltreatment, abuse and violence, teen pregnancy, psychoactive substance use, sexual and reproductive health of adolescents, HIV-AIDS and other sexually transmitted diseases.

Of equal importance is the concern for effective guarantee of child rights in situations of natural or social disaster. Adequate health care and nutrition of children in these situations leaves much to be desired. States are not adequately prepared for these situations, which seemingly are repeated year after year. International aid is limited in time and the ability to respond to the magnitude of these disasters leaving both the rights and health of the child in a precarious and intolerable situation. Prevention and mitigation with a gender and rights based a approach should be a priority for the States.

Practices persist that leave children and adolescents in situations of vulnerability that seriously affect their health, development and physical and mental well-being, such as different forms of violence, abandonment, child labor, slavery, begging, street life, sexual exploitation, linking criminal gangs and armed groups, abduction, trafficking and use in the production and trade of narcotics.

Unwanted and unintended teen pregnancies persist and are complicated by the problems of lack of adequate prenatal and postnatal care. This lack of adequate care generates a high incidence of low birth weight, increased perinatal mortality. These detrimental consequences in the development and health of the child will persist throughout the child’s lifetime.

The issues of child development and mental health continue to occupy a lower level of importance for children, and while there has been an increased concern in recent years for early childhood care, it is more focused on physical care than in the psycho- emotional and social health of the child or adolescent. The mental health of school children and adolescents is a marginal issue that receives little attention and few resources.