OHCHR Study on Children’s Right to Health – Human Rights Council Resolution 19/37
Information from national human rights institution
7 September 2012
OHCHR Specific Questions
1. Please provide information on the main health challenges related to children in your country.
In 2007, the South African Human Rights Commission undertook a public enquiry into health and released a
comprehensive report on health care.1 The SAHRC report found the following in respect to children’s health
care specifically: “In South Africa child survival warrants urgent attention because children continue to die
at an unacceptably high rate from largely preventable causes.2” The issue of under-infant and child
mortality received a great deal of attention. Statistics released by various agencies are variable, however
even the most conservative data sets show a regressive trend with child deaths increasing primarily as a
result of the HIV epidemic which contributes to 40% of deaths of children under five years.
Problematic areas underpinning poor quality care for children included:
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Some facilities were not providing comprehensive obstetric services;
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Referral systems and emergency transport systems were not functioning optimally;
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Staff were demotivated; and
•
Professional nurses did not receive sufficient training in midwifery
In a further study conducted by the South African Human Rights Commission and Unicef in 2011, the
following key indicators were highlighted:3
“A quick review of some of the report’s selected key indicators paint a vivid picture of the levels of inequity
in certain provinces in South Africa:
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1Public
2
nationally, 87% of births take place in public health facilities (in the Eastern Cape, it is 71%);
Enquiry: Access to Health Care Services, www.info.accessibilitygov.za/view/DownloadFileAction?id=99769.
Ibid, p.49.
3
SAHRC, Unicef, Equity in the realization of Child Rights in South Africa, 2011, p.6. www.ecdlc.org.za/index.php/news/advocacynews/79-sahrc-unicef-release-statistics-on-the-realisation-of-child-rights.html.
SAHRC Study on children’s right to health, OHCHR, September 2012 Page 1
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nationally, there is 90% full immunisation coverage among children under one (in Mpumalanga it is
72%);
nationally, there is 18% prevalence of stunting among children 1-9 years (in the Eastern and
Northern Cape, it is 28%);
nationally, there is 5% prevalence of wasting among children 1-9 years (in the Northern Cape, it is
19%);
the national prevalence of HIV among pregnant women is 29% (in KwaZulu-Natal it is 40%);
the national prevalence of HIV among children 2-14 years is 2.5% (in the Free State it is 4.1%);
nationally, 43% of children under five are exposed to an ECD programme (in Gauteng it is 59% and
in KwaZulu-Natal, 33%); and,
nationally, 99% of children of primary-school age attend an educational institution (this figure is
consistent across all provinces).”
“Through continuous reflection on South Africa’s progress in the realisation of children’s rights, and
rigorous engagement with government and relevant stakeholders, we will ensure that all children,
irrespective of the circumstances they are born into, have a chance of a life of dignity and respect and can
thus contribute meaningfully towards the development of their country,” said SAHRC Commissioner
Mokate4.
Arguably the main health challenge to children in South Africa is the risk of HIV/AIDS. The rate of HIV
prevalence and mortality rates have actually stabilised in recent years and by 2011 there was a decrease in
the incidence rates and a reduction in the number of HIV-related deaths.56 However, South Africa still has
one of the largest burdens of HIV and AIDS in the world. This is particularly pertinent with regards to
children, as one in eight children infected with HIV globally, live in South Africa.7
Malnutrition is another serious concern as close to 5% of children suffer from wasting and face a markedly
increased risk of death. A third of all children who died in 2008, were severely malnourished and 60% of the
deaths in that year were associated with malnutrition8. However, South Africa faces a dual burden of overand under-nutrition among youth. Approximately 10% of high school learners are underweight, whereas
approximately 20% are overweight9.
Further health issues related to children is in respect to water and sanitation. Nearly 1.5 million children
(nearly 8%) live in households with no toilet facilities10. Additionally, almost 1.4 million children live in
households relying on rivers or streams as their main source of drinking water.11 Water and sanitation
problems are higher in certain areas. For example, 41% of children without access to toilet facilities live in
the Eastern Cape. Compared to a child growing up in the richest 20% of households, a child in the poorest
20% of households is two times less likely to have access to adequate sanitation and water; two times less
likely to be exposed to early childhood development programmes; seventeen times more likely to
4
5
www.ecdlc.org.za/index.php/news/advocacy-news/79-sahrc-unicef-release-statistics-on-the-realisation-of-child-rights.html.
SANAC and the Government of the Republic of South Africa. (2011). Know your HIV epidemic (KYE) report: Review of the HIV
epidemic in South Africa. Pretoria: SANAC and the Government of the Republic of South
Africa.http://www.sanac.org.za/files/uploaded/KYE%20KYR%20Summary%20Web.pdf Retrieved August 2012.
6 Republic of South Africa. (2012). Global AIDS Response Progress Report 2012. Pretoria: Republic of South Africa.
7 South Africa’s Children: A Review of Equity and Child Rights: Unicef, SAHRC and Department for Women, Children and People with
Disabilities (March 2011) available at;
http://www.sahrc.org.za/home/21/files/SA%20CHILDREN%2024%20MARCH%202011%20SAHRC%20_%20UNICEF%20REPORT.pdf
[accessed August 30 2012], p.36
8 National Perinatal Mortality and Morbidity Committee. (2011). National Perinatal Mortality and Morbidity Committee
(NaPeMMCo) Triennial Report 2008/2011 - 2010.Department of Health: http://www.doh.gov.za/docs/reports/2011/perireport.pdf
Retrieved August 2012
9 Ibid., p.34
10 Ibid., p.29
11 Ibid., p.28
experience hunger; and twenty-five times less likely to be covered by a medical scheme12. In South Africa,
access to services including health care is largely determined by urban and rural divides, often with children
living in rural areas facing the most challenges in relation to health care.
Child mortality is regarded as a huge health challenge in South Africa. Although nine out of ten births now
take place in health facilities, every year some 75,000 children die before their fifth birthday. This is largely
due to HIV and AIDs and poor implementation of existing packages of care.13 It is estimated that 50,000 of
newborn babies and children could be saved in 2015 if South Africa reached effective coverage of key
packages of interventions such as neonatal care.14
2. Please provide information on national policies, strategies and plans of action for addressing the
priority concerns and challenges identified in question 1. Please include information as to whether the
child’s right to health, including the right to health care, is explicitly referred to in existing policies,
strategies and plans of action.
The SAHRC and Unicef held a three-day seminar in March 2011 entitled ‘Equity in the Realisation of Child
Rights in South Africa’. This aimed to allow participants to reflect on the country’s achievements in the
realisation of child rights, and examined the reasons that lie behind persistent disparities. After publishing
the aforementioned report, the SAHRC and Unicef together made the Midrand Declaration15 which
highlighted what needs to be done to reduce inequalities relating to children in particular. The report was
also tabled for discussion at Cabinet.
The SAHRC further hosted a hearing on water and sanitation in March 2012 as part of Human Rights
Month16. Persons from communities were allowed to furnish the Commission with submissions related to
the challenges they face in relation to water and sanitation. Specific submissions were made on the
particular health challenges faced by women, children and persons with disabilities in relation to water and
sanitation. These hearings continue to be undertaken in each province in South Africa currently and will
document the challenges faced by communities in South Africa.
Government Programmes:
Immunisation coverage is a significant element in the prevention of child mortality as it is associated with
child survival and infant and under-five mortality rates.
In April 2010, the upscaled HIV and AIDS Prevention and Treatment Plan was launched. Measures include
that:
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all children under one year of age receive ARV treatment if they test HIV-positive, irrespective of
CD4 level
all patients with both TB and HIV get ARV treatment if their CD4 count is 350 or less
all pregnant HIV-positive women with a CD4 count of 350 or less are started on ARV treatment
all other HIV-positive pregnant women not falling in this category are put on treatment at 14 weeks
of pregnancy to protect the baby
12
Case Study on Narrowing the Gaps for Equity: South Africa, Influencing National Policies to Advance Equity: Unicef (September
2011) available at; http://www.unicef.org/equity/files/ICON_SACO_Equity_Case_Study_Sept2011_FINAL.pdf [accessed August 30
2012], p.2
13 Ibid., p.31
14 Ibid., p.32
15 Statement of the Seminar on Equity in the Realisation of Child Rights in South Africa (“Midrand Declaration”) (2011) available at;
http://www.sahrc.org.za/home/21/files/Midrand%20Declaration%20web.pdf [accessed August 30 2012]
16 ‘SAHRC Launches National Hearing on Water and Sanitation’, available at;
http://www.sahrc.org.za/home/index.php?ipkMenuID=16&ipkArticleID=94 [accessed August 30 2012]
SAHRC Study on children’s right to health, OHCHR, September 2012 Page 3
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a massive counselling and testing campaign has been launched, and all 4 300 public health
institutions in the country are ready to receive and assist patients. By March 2011, six million
people were tested.
Since April 2010, government had also begun to expand the Prevention of Mother-to-Child Transmission
Programme.17
3. Please indicate what role schools have in promoting children’s right to health. Is health promotion
included in the school curricula?
There is a policy entitled ‘National Policy on HIV/AIDS, for learners and educators in public schools, and
students and educators in further education and training institutions’, dated to 199918. The policy states
that learners must receive education about HIV/AIDS on an ongoing basis. Such education must be
integrated into the whole curriculum rather than an isolated content19. This is stipulated to take place in
both primary and secondary grades20. Schools must provide information about HIV, how to avoid it and
teach basic first aid principles. They must emphasise the role of drugs, sexual abuse, violence and sexually
transmitted diseases in transmitting HIV, as well as encouraging the use of healthcare offered by
community service organizations.21 However, the policy permits broad implementation and allows a school
to develop a policy that would reflect its own particular need, ethos and values within the framework of
the national policy.22
In January 2010 the SAHRC wrote to the Eastern Cape Provincial Department of Education to express
concern about the decision of the department to suspend both school transport and nutritional
programmes.23 It was suggested they had done so due to lack of funds. The National Curriculum for Grades
R-9 aims to promote a healthy environment and aims to be sensitive to issues such as HIV/AIDS.24 Health
promotion is included as a goal in the Life Orientation Learning Area Statement.25 Health Sciences and
Social Services is an approved subject in schools in Grades R-12.26
4. Please provide examples of good practices undertaken to protect and promote children’s right to
health, particularly in relation to children in especially difficult circumstances.
The first best practice example undertaken by the SAHRC, as South Africa’s UN “A” status recognized NHRI,
is in respect to the public hearings on health care services which took place in 2007 and the subsequent
report which was released in 2009. The public hearings gave communities the opportunity to bring real
examples of health issues to the attention of the Commission and the report was able to set out clearly the
challenges faced by children in respect to health in South Africa. Furthermore, the report was used as a tool
to monitor government department’s progress in respect to the protection of children’s health rights in
South Africa.
17
18
www.info.gov.za/aboutsa/health.htm
‘National Policy on HIV/AIDS, for learners and educators in public schools, and students and educators in further education and
training institutions’, available at; http://www.education.gov.za/LinkClick.aspx?fileticket=LVkjJsun9Lc%3d&tabid=390&mid=1125
[accessed August 30 2012]
19 Ibid., point 2.10
20 Ibid., point 2.10.2
21 Ibid., point 9.2
22 Ibid., point 2.11
23 ‘SAHRC expresses concern about the suspension of school transport and nutritional programmes by the Eastern Cape
Department of Education’ (January 21 2010) available at;
http://www.sahrc.org.za/home/index.php?ipkMenuID=16&ipkArticleID=37 [accessed August 30 2012]
24 Revised National Curriculum Statement Grades R-9 (Schools), available at;
http://www.education.gov.za/LinkClick.aspx?fileticket=JU1Y7NGqqmk%3d&tabid=390&mid=1125 [accessed August 30 2012], p.10
25 Ibid., p.26
26 National Policy Pertaining to the Programme and Promotion Requirements of the National Curriculum Statement Grades R-12,
available at; http://www.education.gov.za/LinkClick.aspx?fileticket=Rcf0UfEfk5s%3d&tabid=390&mid=1890 [accessed August 30
2012]
The second NHRI best practice example pertains to the fact that the SAHRC has a specific children’s
Commissioner, Commissioner Mokate who focuses on children’s rights. A key example of the SAHRC best
practice is the collaboration between SAHRC, the Department of Women, Children and People with
Disabilities and Unicef, entitled: A Review of Equity and Child Rights. The main aim of the publication and
seminar which was hosted was for the publication to be used as a reference text to assess the state of
South African children to date, address the gaps in policies and service delivery programmes, and project
the way forward to improve the situation of children, especially vulnerable children. The inequalities in the
provision of and access to basic needs have been graphically represented in the text, to give users a
pictorial view of the discrepancies that exist.27 This book may be used to monitor government’s compliance
with both its international and domestic obligations and to ensure that children have equal opportunities
to health care in South Africa.
5. Please indicate what the main barriers are when trying to implement children’s right to health.
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27
The discrepancy in service delivery to rural areas as opposed to urban areas
Implementation problems associated with resourcing, capacity, management, targeting and
delivery mechanisms are inadequate and do not always assist vulnerable communities.28
Insufficient statistics in relation to children and health
Lack of knowledge and awareness raising programmes. Example: Despite healthcare being free for
children under age six, grandmothers and older caregivers who are increasingly taking care of
vulnerable children are at risk of not being aware of this - the immunisation programme, in
particular. Knowledge and information about breastfeeding is also often inadequate.
Additionally, babies are not tested frequently enough for HIV. Of the 800,000 births in 2006, the
HIV status of only 3% was known. This means that they are diagnosed too late; problems that could
have been avoided may have already set in.29
SAHRC, Unicef, Department Women, Children and People with Disabilities, 2011, p.6. www.ecdlc.org.za.
28
Scaling up Nutrition: A Framework for Action. Center for Global Development; International Conference on Nutrition; the
European Commission; the United Nations Standing Committee on Nutrition; USAID; UNICEF; WFP; WHO; World Bank:
http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/PolicyBriefNutrition.pdf Retrieved August
2012
29 Ibid., p.134
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