Contributions to the General Comment on UNCRC Article 24
Rights of the Child to Enjoy the Highest Level of Health
Corresponding Author
Jeffrey Goldhagen, M.D., MPH
Department of Pediatrics
University of Florida, College of Medicine
653 W. Eighth Street
Jacksonville, FL 32082
Phone: 1.904.244.5198
Email: Jeffrey.Goldhagen@jax.ufl.edu
Raul Mercer M.D., MSc
Program of Social Sciences and Health
FLACSO (Latin American School of Social Sciences)
Buenos Aires, Argentina
Gary Robinson Ph.D.
Child Rights Education for Professionals (CRED – PRO)
IICRD, University of Victoria, Canada
Ernesto Duran
Director, Observatory of Child Rights
National University
Bogota, Colombia
Elspeth Webb, M.D.
Department of Child Health
Cardiff University School of Medicine
Cardiff, Wales
The Corresponding Author, Jeffrey Goldhagen, M.D., MPH is a Professor of Pediatrics at the University
of Florida College of Medicine, and has more than two decades of experience working at the intersection
of child health and child rights. He is the author of numerous peer reviewed articles and book chapters on
the principles of child rights and their translation into child health practice; has lectured extensively on
these topics in international venues and is the lead author of the American Academy of Pediatrics Policy
Statement on Child Rights and Health Equity. In collaboration with co-authors, Raul Mercer, M.D., Gary
Robinson, Ph.D., and Ernesto Duran, the Southern Cone Initiative (2005) was established in South and
Central America to train health professionals in child rights and health equity. In partnership with coauthor Elspeth Webb, M.D., and other members of the Royal College of Paediatrics and Child Health and
the American Academy of Pediatrics (AAP), the Equity Project (2001) was established to introduce the
principles and practice of child rights and child health equity into the respective organizations. Most
recently, Dr. Goldhagen, in collaboration with the co-authors and other colleagues, is leading the
development of the first post-graduate fellowship training in Community Pediatrics and Child Rights. He
is the 2011 recipient of the AAP Job Lewis Smith Award for his work in child rights and health equity.
Contributions to the General Comment on UNCRC Article 24
Rights of the Child to Enjoy the Highest Level of Health
Corresponding Author
Jeffrey Goldhagen, M.D., MPH
Professor, Department of Pediatrics
University of Florida, College of Medicine
653 W. Eighth Street, Jacksonville, FL 32082
Phone: 1.904.244.5198/Email: Jeffrey.goldhagen@jax.ufl.edu
Introduction
The Universal Declaration of Human Rights emerged in the aftermath of the 2nd world war. The
“Right to Health,” first expressed in this declaration, is enshrined in the constitution of the World
Health Organisation (WHO). The core principles of the Declaration and subsequent human rights
documents, e.g., universality, indivisibility, non-discrimination and participation, are concordant
with the underlying precepts of medicine, medical practice, public health and the principles of
medical ethics—beneficence, non-malfeasance, justice and autonomy. Yet, despite more than a halfcentury of enlightenment as to the relevance of human rights to the health and well-being of
individuals and communities; and more recently rapid advances in knowledge of social epidemiology
and the life course sciences, the principles of human rights, social justice and equity have not been
well integrated into the foundation and framework of professional and societal standards for the
development of health systems and the generation of relevant public policy. Furthermore, despite the
availability of strategies and tools, including the UN Convention on the Rights of the Child
(UNCRC) itself, the principles of human rights, social justice and equity have not been translated
into health professional training and the delivery of health services. General Comment, Article 24
should be grounded in the historical and developmental context of global health and human rights.
National and international health systems across the economic spectrum of countries remain
focused primarily on access to health care and dependence on biomedical treatment. Global public
and private sector health policies, systems and practices have not fully responded to the complexity
of the social, economic, political-civil, environmental and cultural factors that generate health. They
have arguably not fully engaged a rights and equity-based approach to policy and practice. This
reflects the ongoing tension that has existed since the Alma Ata (1978) and Bellagio (1979)
conferences. The chasm between knowledge/experience and policy/practice should be acknowledged
and addressed by General Comment, Article 24.
While the ecology of health has changed dramatically since the1970s, the approaches to health
systems and programs have not. In spite of the adoption of several human rights documents [UN
Convention on the Rights of the Child (1979), Ottawa Charter for Health Promotion (1986), African
Charter on the Rights and Welfare of the Child (1999), UN Convention on the Rights of People with
Disabilities (2006)], Selective Primary Care (Child Survival), for example, remains the priority
strategy of many international organizations to address the health and well-being of children in low
and middle income countries. Without engaging and integrating complementary rights-and equitybased strategies, Child Survival interventions will never be sufficient to achieve health equity and
optimal outcomes for the health and well-being of children, including the Millennial Development
Goals. General Comment, Article 24 should address the necessity of all public and private sector
national and international organizations and agencies to engage rights and equity-based strategies
to accomplish desired child health outcomes.
As health systems reflect the values of the societies they serve—societal discrimination is
mirrored by health system inequities in access and quality of care, and lack of attention to the rootcause determinants of health. The configuration of health systems throughout the world results in
those with the most need being least well served. Innumerable examples of institutional/structural
discrimination exist in health practice and systems. General Comment, Article 24 must acknowledge
and address societal discrimination in health by implementing rights and equity-based strategies.
To succeed, General Comment, Article 24 must also acknowledge the unique and profound
obligation professionals, and in particular child health professionals, have to uphold and implement
the principles underpinning equity and the right to health. To fulfil this obligation, all health
professionals must be informed by a robust knowledge of health equity and human rights, and
develop the competencies to translate these principles into practice in the clinical setting, community
and through the generation of public policy. This is essential to enable child-serving professionals to
not only promote fairness and social justice in all aspects of clinical practice and systems
development, but also to prevent health professional complicity in human rights abuses. It is critical
to the relevance and future of pediatrics and child health, that children and families not be harmed by
the health organisations, systems and professionals they trust. GC-Article 24 should explicitly
address the integration of the principles and tools of health equity—human rights, social justice,
human capital investment and health equity ethics—into all aspects of the education of
undergraduate, graduate and postgraduate child health professionals.
Toward these ends, the following premises are presented to serve as a foundation and framework
for the formulation of General Comment, Article 24. General Comment, Article 24 must not only
address principles and normative standards, but also provide strategies for the translation of these
principles and standards into practice and systems development.
Basic premises for the realization of children’s right to health
Premise 1. General Comment, Article 24 should embrace the World Health Organization’s
(WHO) definition of health as the context for developing strategies for the fulfilment of the child’s
right to health. This would ensure all the prerequisites for not only health, but also health related
quality of life, are addressed and fulfilled. GC-Article 24 should thus expand its focus from “health”
to “health and well-being.” This will impact all aspect of the implementation and measurement of
strategies related to UNCRC Article 24.
Premise 2. General Comment, Article 24 should expand the dialog and discourse from “rights”
to “equity.” Engaging Child Health Equity, defined as including the domains of: a) child rights, b)
social justice, c) human capital investment and d) health equity ethics, increases the breadth and
depth of resources available to address the spectrum of health determinants impacting child health
and the strategies to ensure optimal child health and eliminate disparities.
Goldhagen J, Etzel R, Melinkovich P and the Council on Community Pediatrics and Committee on Native American
Child Health. Policy Statement. Health equity and children's rights. Pediatrics. 2010;125(4):838-849
Premise 3. General Comment, Article 24 should: a) use the knowledge and experience accrued
over the past decades with respect to the root-cause social and environmental determinants of health
as its foundation and framework; and b) inform states, professionals and other relevant stakeholders
how to translate the principles of equity and rights into the delivery of health services, the
development of health systems and the generation of relevant public policy.
Premise 4. UNCRC Article 24 is arguably among the most complex rights to fulfil. This is
particularly true given the increased understanding of the impact of social and environmental
determinants, maternal health pre- and during gestation, maternal and paternal mental health, etc.
on the health and well-being of children. Advances in knowledge related to the impact of child
health on adult health trajectories greatly magnify the importance of fulfilling the child’s right to
health. Thus, in addition to the broad array of closely related articles within the UNCRC (articles
2,3,56,12,17,18,19,23,25,27,28,29,32-36, and 39), GC-Article 24 must address the necessity of also
engaging other human rights convention and documents, in particular those related to the health and
well-being of women, as a necessity to fulfil the rights of children to health.
Premise 5. Many national and international state and institutional health policies remain
grounded in a biomedical model focused on access to health care and selective primary care (Child
Survival). These models have diminishing relevance to contemporary epidemiology and scientific
knowledge of child health. Global health policies must establish a rights and equity-based
foundation and framework for the delivery of health services and structure and function of health and
related sector systems to address child health. These services and systems must conceptualize the
UNCRC as a strategy and tool, engage current and develop new rights and equity-based tools that
respond to root-cause determinants of child health.
Premise 6. General Comment, Article 24 should adopt a public health approach to fulfilling
child health rights. The United States Institute of Medicine’s report on public health identifies three
core functions of public health—Assurance, Policy, Assessment—that could be used to frame all
aspects of the work of states, professionals and stakeholders related to UNCRC Article 24.
How can the principles of the CRC, in particular articles 2, 3, 6 and 12 be applied to designing,
implementing and monitoring interventions to address health challenges and what aspects are
specific to a child’s rights approach to health.
Premise 7. The knowledge and tools exist to transform the structure and function of health
services and systems into rights and equity-based systems of care. General Comment, Article 24
must provide the leadership; establish the goals, objectives and tasks; provide access to the tools and
define the metrics required to accomplish this transformation. GC-Article 24 should, at a minimum:
 Recognize and address the complex interplay of social and environmental determinants of
children’s health and well-being.
 Re-contextualize the UNCRC as a tool/matrix that can be used to identify and frame the
response to the complex interplay of child health determinants.
 Establish a common health systems framework to analyze and address child health services,
systems and policies.
 Advance the requirements of states and institutions to identify the proximal determinants of
children’s health prior to implementing prevention and mitigation strategies.
 Catalyze the development of rights and equity-based tools that can be used to advance the
health and well-being children.
 Catalyze the development of curricula to prepare professionals to use/evaluate these tools.

Ensure child and youth participation.
What is the normative content of article 24? What are the specific obligations of States under
article 24? What are the responsibilities of non-state actors? What are the priority concerns in
general and in particular regions for the implementation of article 24?
Premise 8. Advances in our knowledge and understanding of the impact of social and
environmental factors on health; and the biology and physiology underpinning this impact, requires
a parallel change in virtually every aspect of our strategies to optimize the health and well-being of
all children and the adults they will become. These strategies must be rights and equity-based in
order to succeed. General Comment, Article 24 must seek a radical departure from historical
medical models to embrace rights and equity-based models of health services, systems and policies.
Premise 9. States should embrace the principles of systems-of-care development with respect to
developing, implementing and evaluating the systems and practices required to fulfil the health rights
of children. These principles include the necessity of systems and practices, at a minimum, to be
family driven, youth guided, culturally and linguistically competent and evidence-based.
Premise 10. Children and youth, and in particular those marginalized by social and
environmental determinants, disabilities and medical conditions, must be fully engaged in defining,
developing, implementing and evaluating systems and practices related to the broad spectrum of
initiatives required to fulfill the rights of children and youth to optimal health and well-being.
Metrics to measure child and youth participation must be established and used for assessment and
quality improvement.
Premise 11. States cannot devolve or relinquish their responsibility through privatization,
outsourcing or other strategies; nor as a result of externally imposed restrictions—for policy
development, assurance and assessment of a child’s right to health. This relates to states’ own
internally generated policies for privatization of public health programs and health service; as well
as internationally imposed policies related to structural adjustment and economic policies.
Premise 12. States must use the UNCRC articles related to health, and in particular the core
principles (articles 2,3,6, 12 and 17), to frame, implement and evaluate all policies, programs and
systems that impact child health. Given the child’s right to health, the impact of health on the
realization of all other rights, the societal impact of child health on her/his well-being and the effects
of children’s health on the adult life course, the child’s right to health must be a priority for states’
distribution of resources and other public policies.
Premise 13. The neglect and indifference toward the principles of child rights and equity in
relation to health, and the general disregard of the social and environmental determinants of health
and life course sciences in the education of health professionals, have and continue to contribute to
the failure to reach Millennial Developmental Goals, suboptimal societal health and disparities
among large populations of people marginalized by race, sexual orientation, age, gender, disability,
social status, etc. General Comment, Article 24 must address the priority of advancing professional
education in health and human rights at the institutional level. This education must be evidencebased and link social and medical science with practice.
Premise 14. With advances in our knowledge related to brain development, it has become
increasingly clear that both child and adult physical and mental health and well-being is determined
early in childhood. Also, the WHO explicitly includes mental health within its definition of health.
In general, mental health has been neglected in the discourse of child health. General Comment,
Article 24 must include a focus on children’s mental health, including the need to address early brain
development as a critical element of a child’s right to health.
Which concrete measures should be put in place to implement article 24?
Premise 15. The metrics used to measure the success of General Comment, Article 24 must
include its capacity to both prepare states, professionals and other stakeholders how to respond to
root causes of contemporary child health determinants, as well as prevent and mitigate future health
issues, e.g., impact of globalization and climate change on children.
Premise 16. General Comment, Article 24 should establish two levels of indicators: a) Outcome
indicators that can be used as metrics across countries, and b) Proximal Determinant Indicators that
can be used to address root cause determinants unique to individual countries.
Premise 17. Metrics used to evaluate the design, implementation and formative and summative
outcomes of policies, systems, programs and practices related to UNCRC Article 24 should be
structured as equity indicators—indicators that identify and measure the full spectrum of the
etiologies of child health and well-being and outcomes of systems and programs. General Comment,
Article 24 should explicitly move the science of measurement from quantifying disparities to
assessing and mitigating the root causes of disparities and suboptimal child health and well-being.
Premise 18. Health equity indicators cannot be based/measured by aggregate data. Data
related to systems, practices and health outcomes must be disaggregated to reflect disparities based
on geographic, gender, socio-economic, political, cultural and environmental determinants.
Premise 19. Given the impact of social, economic, political, cultural and environmental
determinants on child health and well-being; health equity indicators must measure these root-cause
determinants in the context of formative and summative assessments of all aspects of state,
professional and stakeholder efforts to fulfil the health rights of children.
The Corresponding Author, Jeffrey Goldhagen, M.D., MPH is a Professor of Pediatrics at the University of Florida
College of Medicine, and has more than two decades of experience working at the intersection of child health and
child rights. He is the author of numerous peer reviewed articles and book chapters on the principles of child rights
and their translation into child health practice; has lectured extensively on these topics in international venues and is
the lead author of the American Academy of Pediatrics Policy Statement on Child Rights and Health Equity. In
collaboration with co-authors, Raul Mercer, M.D., Gary Robinson, Ph.D., and Ernesto Duran, the Southern Cone
Initiative (2005) was established in South and Central America to train health professionals in child rights and health
equity. In partnership with co-author Elspeth Webb, M.D., and other members of the Royal College of Paediatrics
and Child Health and the American Academy of Pediatrics (AAP), the Equity Project (2001) was established to
introduce the principles and practice of child rights and child health equity into the respective organizations. Most
recently, Dr. Goldhagen, in collaboration with the co-authors and other colleagues, is leading the development of the
first post-graduate fellowship training in Community Pediatrics and Child Rights. He is the 2011 recipient of the
AAP Job Lewis Smith Award for his work in child rights and health equity.