Why it is essential to protect and ringfence child health services in the context of austerity

 

One in every three people in South Africa are children under the age of 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 our youngest citizens are disproportionately concentrated in the poorest households and are highly vulnerable to shocks such as the COVID-19 pandemic and the current economic recession. 

 

At the Child Health Priorities Conference, hosted at the University of the Witwatersrand in late 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 whilst simultaneously pushing more children even deeper into poverty.

 

A call to action

The United Nations 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 health care system to take proactive steps to safeguard and ringfence budgets for child health services to ensure that the proposed austerity measures do not introduce retrogressive measures or erode children’s rights to health care services.

Here we draw on the latest science, economic and legal arguments to support the call for the protection and ringfencing of budgets for child health services.  

1. Children’s health and access to health care services are already compromised

• Even before the pandemic, 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 1.5 million children into food poverty – so that by 2020, 4 in every 10 children lived in households that could not afford to meet their children’s nutritional needs.
• Post-COVID, rising food and fuel prices have further been eroding children’s food security, nutritional status, and access to health care services.
• The reduced utilisation of routine primary health care 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:

• 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 (undernutrition, obesity, micronutrient deficiencies) is fueling the acceleration of non-communicable diseases that threatens to overwhelm the health care 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 prior to childbearing has the potential to kickstart 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 systematic review 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 1000 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 Framework, Global 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 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 its 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, 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

Organisational endorsements

Centre for Child Law, University of Pretoria 

Child PIP Executive Committee
Children’s Institute, University of Cape Town

ChildSafe South Africa

Child and Adolescent Mental Health Services Strengthening Team

Department of Paediatrics and Child Health, University of Cape Town

Department of Paediatrics and Child Health, University of Stellenbosch

Department of Paediatrics and Child Health, University of KwaZulu-Natal

Department of Paediatrics and Child Health, University of the Witwatersrand

Department of Paediatrics and Childhood, University of Pretoria

Department of Paediatrics, Mitchells Plain Hospital

Groote Schuur Hospital Adolescent Centre of Excellence

Harry Crossley Children’s Nursing Development Unit, University of Cape Town

Healthy Living Alliance (HEALA) 

Institute for Life Course Health Research, University of Stellenbosch

Mowbray Maternity Hospital, Neonatal Medicine Department

PaedsPal

Paediatric Students Society, University of Cape Town

People’s Health Movement of South Africa

Rural Health Advocacy Project

Section27

South African Civil Society Organisation for Women’s, Adolescent and Child Health (SACSOWACH)

South African Paediatrics Association

 

 

Individual endorsements

1. Professor Ute Feucht, Department of Paediatrics, University of Pretoria
2. Dr Wiedaad Slemming, Division of Community Paediatrics, University of the Witwatersrand
3. Professor Haroon Saloojee, Division of Community Paediatrics, University of the Witwatersrand
4. Professor Ashraf Coovadia, Department of Paediatrics and Child Health, University of the Witwatersrand
5. Professor Neil McKerrow, Departments of Paediatrics, Universities of Cape Town and KwaZulu-Natal
6. Professor Shanaaz Mathews, Children’s Institute, University of Cape Town
7. Lori Lake, Children’s Institute, University of Cape Town
8. Professor Maylene Shung-King, School of Public Health, University of Cape Town
9. Professor Mark Tomlinson, Institute of Life Course Health Research, University of Stellenbosch
10. Dr Dave le Roux, Department of Paediatrics and Child Health, University of Cape Town 
11. Dr Mandy Wessels, Executive Chairperson Child PIP
12. Dr Yogan Pillay, Department of Global Health, Stellenbosch University 
13. Dr Denise Evans, Health Economics and Epidemiology Research Office, University of the Witwatersrand
14. Nozipho Musakwa, Health Economics and Epidemiology Research Office, University of the Witwatersrand
15. Emeritus Professor Andrew Argent, Department of Paediatrics and Child Health, University of Cape Town
16. Professor Petrus de Vries, Division of Child and Adolescent Psychiatry, University of Cape Town 
17. Dr Chantell Witten, Centre of Excellence in Food Security, University of the Western Cape
18. Dr Joan van Niekerk, National Representative for Children on the Civil Society Forum of South African National AIDS Council
19. Dr Diane Gray, Department of Paediatrics and Child Health, University of Cape Town
20. Dr Catherine Mathews, South African Medical Research Council
21. Dr Max Kroon, Department of Paediatrics and Child Health, University of Cape Town
22. Dr Thandi Wessels, Department of Paediatrics and Child Health, University of Stellenbosch
23. Dr Rowan Dunkley, General Paediatrician, Red Cross War Memorial Children’s Hospital.
24. Dr Jaco Murray, Department of Paediatrics and Child Health, Paarl Hospital.
25. Dr Nomlindo Makubalo, Department of Health, Eastern Cape
26. Dr Gabriel Urgoiti, RX Radio
27. Nzama Mbalati, Health Living Alliance (HEALA)
28. Prof Regan Solomons, Department of Paediatrics and Child Health, University of Stellenbosch
29. Prof Adrie Bekker, Department of Paediatrics and Child Health, University of Stellenbosch
30. Prof Angela Dramowski, Department of Paediatrics and Child Health, University of Stellenbosch
31. Dr. Gugu Kali, Department of Paediatrics and Child Health, University of Stellenbosch
32. Dr Sandi Holgate, Department of Paediatrics and Child Health, University of Stellenbosch 
33. Dr Lisa Frigati, Department of Paediatrics and Child Health, University of Stellenbosch
34. Dr Krisna Keyser, Department of Paediatrics and Child Health, University of Stellenbosch
35. Dr Jameel Busgeeth, Department of Paediatrics and Child Health, University of Stellenbosch
36. Dr Angeline Thomas, Department of Paediatrics and Child Health, University of Stellenbosch
37. Dr. Minette Maree, Department of Paediatrics and Child Health, University of Stellenbosch
38. Dr Nomusa Mfeka, Department of Paediatrics and Child Health, University of Stellenbosch
39. Dr Muneerah Satardien, Department of Paediatrics and Child Health, University of Stellenbosch
40. Dr RC Krause, Department of Paediatrics and Child Health, University of Stellenbosch 
41. Dr Audrey Sullivan, Department of Paediatrics and Child Health, University of Stellenbosch
42. Dr Pippa Durr, Department of Paediatrics and Child Health, University of Stellenbosch
43. Dr Netta van Zyl, Department of Paediatrics and Child Health, University of Stellenbosch
44. Dr Odette Viola, Department of Paediatrics and Child Health, University of Stellenbosch
45. Dr Chane Kay- Paediatrics Karl Bremer hospital 
46. Dr Natasha O’Connell – Khayelitsha district Hospital 
47. Jane Booth, retired nurse at Breatheasy Programme
48. Dr Rene Nassen, Department of Psychiatry, University of Stellenbosch
49. Dr James Porter, False Bay Hospital
50. Dr Shamiel Salie, Department of Paediatrics and Child Health, University of Cape Town
51. Dr Louise Cooke, Department of Paediatrics and Child Health, University of Cape Town
52. Dr Ariane Spitaels, Department of Paediatrics and Child Health, University of Cape Town
53. Dr Graham Spittal, Department of Paediatrics, Mitchells Plain Hospital
54. Emeritus Professor Louis Reynolds, Department of Paediatrics and Child Health, University of Cape Town
55. Professor Rina Swart, DSI-NRF Centre of Excellence in Food Security, University of the Western Cape
56. Dr Claire Procter, Department of Paediatrics and Child Health, University of Cape Town
57. Dr Andrew Redfern, Department of Paediatrics and Child Health, University of Stellenbosch
58. Professor Alan Davidson, Department of Paediatrics and Child Health, University of Cape Town
59. Dr Phumza Nongena, Department of Paediatrics and Child Health, University of Cape Town 
60. Dr Marja Wren-Sargent, Department of Paediatrics and Child Health, University of Cape Town
61. Professor Heather Zar, Department of Paediatrics and Child Health, University of Cape Town
62. Dr Thandi de Wit
63. Professor Michael Levin, Department of Paediatrics and Child Health, University of Cape Town
64. Dr Marc Hendricks, Department of Paediatrics and Child Health, University of Cape Town
65. Dr Wendy Vogel, Department of Paediatrics and Child Health, University of Cape Town
66. Dr Kate Webb, Department of Paediatrics and Child Health, University of Cape Town
67. Dr Aleya Remtulla, Department of Paediatrics and Child Health, University of Cape Town
68. Professor Marco Zampoli, Department of Paediatrics and Child Health, University of Cape Town
69. Dr Peter Nourse, Department of Paediatrics and Child Health, University of Cape Town
70. Dr Zakira Mukkadem-Sablay, Department of Paediatrics and Child Health, University of Cape Town
71. Dr Michelle Meiring, Department of Paediatrics and Child Health, University of Cape Town
72. Dr Sanja Nel. SAMRC Maternal and Infant Health Care Strategies Unit, Pretoria 
73. Dr Helen Mulol, SAMRC Maternal and Infant Health Care Strategies Unit, Pretoria 
74. Dr Yaseen Joolay, Division of Neonatal Medicine, University of Cape Town
75. Dr Tanya Doherty, Health Systems Research Unit, South African Medical Research Council 
76. Professor Refiloe Masekela, Department of Paediatrics and Child Health, University of KwaZulu-Natal
77. Dr Kate Baume, Department of Paediatrics and Child Health, University of Cape Town
78. Dr Ben van Stormbroek, Department of Paediatrics and Child Health, University of Cape Town
79. Dr Gill Shermbrucker, Department of Paediatrics, Victoria Hospital
80. Dr Kirsten Reichmuth, Department of Paediatrics and Child Health, University of Cape Town
81. Dr Sydney Bongani Nkosi, Niemeyer Memorial Hospital
82. Professor Michael Hendricks, Department of Paediatrics and Child Health, University of Cape Town
83. Emeritus Associate Professor Tony Westwood, Department of Paediatrics and Child Health, University of Cape Town 
84. Professor Chris Scott, University of Cape Town Clinical Research Centre
85. Professor Mignon McCulloch, Department of Paediatrics and Child Health, University of Cape Town
86. Emeritus Professor Marian Jacobs, Faculty of Health Sciences, University of Cape Town
87. Professor Rajendra Bhimma, Department of Paediatrics and Child Health, University to KwaZulu-Natal
88. Dr Nox Mbadi, Addington Hospital
89. Lucy Jamieson, Children’s Institute, University of Cape Town
90. Nonhlanhla Mtolo, Children’s Nursing Development Unit, University of Cape Town
91. Dr Lyndall Gibbs, PaedsPal
92. Professor Minette Coetzee, Harry Crossley Children’s Nursing Development Unit, University of Cape Town
93. Dr Papani Gasela, Division of Child and Adolescent Psychiatry, University of Cape Town
94. Professor Sharon Kleintjes, Department of Psychiatry and Mental Health, University of Cape Town
95. Dr Kimesh L Naidoo, KwaZulu-Natal
96. Dr Radhika Singh, KwaZulu-Natal
97. Professor Moherndran Archary, KwaZulu-Natal 
98. Dr Visva Naidoo. KwaZulu-Natal
99. Dr Ayanda Msomi. KwaZulu-Natal
100. Dr Leanne Munian, KwaZulu-Natal
101. Dr Gugulethu Buthelezi, KwaZulu-Natal 
102. Dr Zohra Banoo, KwaZulu-Natal
103. Dr Nomgcebo Mzizana, KwaZulu-Natal 
104. Dr Yasha Kannigan, KwaZulu-Natal 
105. Bright Makhubedu, PaedSoc (Paediatric Student Society), University of Cape Town
106. Jane Vos, Harry Crossley Children’s Nursing Development Unit, University of Cape Town
107. Dr Rajas Naidoo, DCST West Rand District
108. Dr Romolo Naidoo, DCST Ugu District 
109. Dr Cindy Stephen, Child PIP EXCO
110. Dr Mark Patrick, Child PIP EXCO
111. Dr Kim Harper, Child PIP EXCO 
112. Dr Lesley Bamford, Child PIP EXCO 
113. Dr Ndaye Kapongo, KwaZulu-Natal
114. Dr Jodi Wiles, KwaZulu-Natal
115. Dr Nomonde Bhengu KwaZulu-Natal

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