Every child to thrive, belong and achieve? Time to reflect and act in New Zealand

New Zealand (NZ) is a world-leader in child health and development research1 and ratified the United Nations Convention on the Rights of the Child (UNCROC2) nearly 20 years ago. Despite these achievements, our child outcomes are extraordinarily poor with large equity gaps.NZ was ranked second to last in health and safety of 30 countries in an OECD report on child wellbeing and did not score highly in any category.3 Public investment in children is low by OECD standards throughout childhood, and is less than half the OECD average for our youngest children.3Knowledge of this state of affairs is not new.4 Reports over the last decade have expressed concern and called for improvement. We recognise that there have been some advances such as in immunisation, and recent investments in rheumatic fever, Whānau Ora, and Gateway Assessments.Recent developments include the Government's Green Paper on Vulnerable Children with its laudable vision of "Every Child Thrives, Belongs, Achieves" and the Māori Affairs Select Committee Inquiry into the Determinants of Wellbeing for Māori Children.5,6 It appears that the desire to do better is growing and currently there may be significant opportunities for positive change.The health of New Zealand childrenWhile major causes of mortality, such as injury and sudden unexpected death in infancy (SUDI) have been declining, the rate of decline has been less than in other nations and inequalities have persisted or even widened.7Socioeconomic conditions have had a major impact on child health. Hospitalisations for socioeconomically sensitive conditions such as infectious and respiratory diseases steadily increased for children during the 1990s and early 2000s, with the significant rises occurring for those from lower socioeconomic backgrounds, particularly for Māori and Pacific peoples.8,9 During this period, NZ experienced major socioeconomic changes, the second largest increase in income inequality in the OECD, and a marked rise in child poverty.10-12These hospitalisations peaked in 2002, gradually declined, and increased during 2007-2010, resulting in around 4800 extra admissions in 2010 compared to 2007.13Disparities are seen across a range of child health indicators and can be observed very early on in life. For example, Māori infants are nearly five times more likely to die from SUDI than European infants.13Māori and Pacific children bear the greatest burden of ill-health and there is a social gradient evident for most conditions (i.e. with rates progressively increasing with increasing socioeconomic deprivation). Such disparities are well illustrated with NZ's 14-fold higher rate of rheumatic fever compared to the OECD average, the burden of which predominantly falls on Māori and Pacific children and children living in more deprived areas.8Similarly, hospitalisation rates for injuries arising from maltreatment demonstrate a marked social gradient, with rates rising from 4.2 per 100,000 for children living in the least deprived areas to 42.2 per 100,000 for those from the most deprived areas.13 This gradient across the population shows that such outcomes are not confined to those living in the most deprived areas, but affect children throughout society.While trends for many conditions have been disappointing, some gains have been made. Immunisation rates, for example, have steadily improved so that by the end of 2011 more than 90% of 2 year olds are fully immunised and disparities have markedly reduced.14 This has been due to leadership, the effective use of target setting, infrastructure such as the national immunisation register, effective service delivery and use of specific evidence-based strategies.14The environment, early relationships, and children's healthThe social and physical environment has a powerful effect on children's health with complex and interactive pathways being involved. For example a respiratory illness can be the result of the transmission of the pathogen (encouraged by overcrowding), host factors (such as being more vulnerable from poor nutrition or chronic stress) the physical environment (damp housing, exposure to tobacco smoke) and the social environment (access to health care services, parental education, social support).15While genetic variation accounts for some diseases, of far more importance are diseases that occur as a result of the way in which the genome interacts with its environment. From the moment of conception factors such as maternal nutrition, the presence of stress, and the effects of various molecules including toxins such as alcohol, influence chromosomal activity in the developing fetus.1,16Crucial maturation processes continue during early childhood, and these are critically shaped by the milieu of each child. This period of rapid brain and organ development can be profoundly influenced by a lack of nurturing and secure relationships and the presence of "toxic" stress such as violence.16-18These exposures can divert brain development away from learning and skill development to a persistently activated physiological stress response, the long-term impact of which depends on intensity, duration and the presence of protective factors such as supportive relationships.17These negative early life circumstances can have life-long consequences resulting in poorer social and cognitive skills and poor mental resilience in later life. Many chronic diseases of adulthood, such as cardiovascular disease and mental illness, as well as longevity itself, are linked to early life circumstances.1,18The impact of poverty on child health and wellbeing also involves complex pathways. One important example may be the impact of economising behaviours or "enforced lacks" such as children having to share a bed or several to a bedroom, cutting back on fresh fruit and vegetables, having difficulties heating the house in winter, being exposed to damp or mouldy housing and postponing doctor's visits because of cost.These economising behaviours are a common experience for many children in NZ. The 2008 Living Standards Survey found that over half (51%) of Pacific children aged 0-17 years, 39% of Māori children, 15% of European children, and 59% of children whose main source of family income was a Government benefit scored four or more on a composite deprivation index of "enforced lacks".13Hence efforts to improve child health and equity must consider the impact of social conditions, the wellbeing of parents, and the social and economic policies which shape these.19The imperatives for actionThere is a compelling case for a special focus on children. Firstly, there is an ethical and rights-based argument. The United Nations Committee on the Rights of the Child (UNCROC) acknowledges the special position of children in society; that the best interests of children must be a primary concern in decision-making, and that the family should be afforded protection and assistance so that it can fully assume its care-giving responsibilities.2Successive Governments have committed to progressively realising this international treaty in our legislation, policy and practice.20 However, children do not vote and there are currently no formal mechanisms in place to ensure that their rights and interests are considered in public policy decision-making processes.4,12Last year the UNCROC provided further recommendations to the NZ Government, including the need for a coordinating mechanism, an action plan, urgent action to address disparities for Māori children, greater resource allocation for children, greater consideration of the views of children, and reduced discrimination, maltreatment and violence.21Secondly, there is an outcomes-based argument. Reducing morbidity and mortality in children is important in itself. However, early childhood is also a crucial time for adult development and for attaining more equitable health and social outcomes throughout the lifecourse.22,23A healthy start to life produces individuals who are more likely to participate effectively in society and who are less likely to contribute to the growing burden of long term conditions such as mental illness, type 2 diabetes and cardiovascular disease.17Thirdly, there is an economic argument. Two recent NZ reports estimate the economic cost of a poor start to life as being in the order of 3 to 4.5% of GDP per year (at least $6 billion), due to increased expenditure on health, welfare, education, and criminal justice and lower productivity.24,25Finally, there is a societal argument around what sort of community NZ wishes to be and what we value as a nation. Media reports of child abuse receive brief intense moments of attention and there is rhetoric around the desire to be a more cohesive, caring and less inequitable society. These reports are often followed, however, by uncertainty about how to move from the unacceptable present.Challenges and opportunitiesGiven the compelling case for action, how can further progress be gained? There is no shortage of excellent reports, analyses, recommendations and strategic documents.3,4,7,19,21,26-32There have been some important gains, such as the repeal of Section 59 of the Crimes Act to provide better protection of children from assault. If focused on children, there is much to be gained from the growing use of quality improvement approaches within the health sector.There is promise from recent investments in Whānau Ora, Integrated Family Health Centres, Gateway Assessments, and a disease focus such as for rheumatic fever. However, overall, action remains fragmented, insufficient and lacking a coordinated national framework across health and other sectors.4We acknowledge that the current fiscal environment presents challenges and will do so for some time. However, as NZ's poor performance in child health and wellbeing predated the global financial crisis and recession, the barriers to action are more complex than a difficult economic climate alone. Furthermore, our current approach is costly and unsustainable.24,25Solutions are complex and cross agency and disciplinary boundaries. One of the fundamental difficulties is that there are strongly-held disparate views on the causes of the problem, and hence, the solutions. The issues can become polarised and entrenched in rhetoric and emotion.There is a perceived tension between differing beliefs of who ought to be responsible —creating a false dichotomy between the roles of parental authority and the State. Parents and caregivers have the primary responsibility for child-rearing, however not in isolation; the broader environment within which the family is living also affects their child-rearing capacity and child outcomes.The Government and civil society can do much to support the role of parents and to ensure good outcomes for our children.2,17 Furthermore, there is the need to acknowledge children as citizens, competent in their own right and able to exercise agency, while still needing to be nurtured and protected.2,33A further challenge relates to balancing the needs of the growing child with the advantages from having a parent in paid work. There may be a tension between paid work and the important role of child-rearing, particularly if employment is poorly paid, is not family-friendly, or if quality child care is not affordable or available.NZ has a high proportion of children living in one-parent families (28% of families), where the likelihood of poverty and deprivation is much higher.34 The majority of one-parent families are headed by mothers (23.5% of families) compared to 4.7% headed by fathers.34While paid employment may be potentially the best way out of hardship, particularly over the longer term, in NZ about 40% of children in poverty are from families with at least one full-time worker.35There appears to be a general recognition in NZ of the need for a basic level of provision by the State for children. However the optimal level and adjustment of this has varied since the 1980s, with more recently, a discriminatory lower level of State provision for children of beneficiaries than for other children,36 unlike the universal basis of superannuation with an inflation-adjusted set baseline.The economic challenge of sustaining this level of superannuation is not reason to avoid the dialogue on what should be a basic level of provision for children.Finding a way forwardWhile there are many areas of uncertainty, some issues are clear. NZ's child health and wellbeing statistics are not acceptable. There is recognition of the need for all children to receive the necessary provisions for healthy growth and development. However how to achieve this has not been agreed. Our current approach of piecemeal, ad hoc action is not sufficient.There is not one simple solution for NZ or indeed for other comparable countries and there will remain areas of significant debate about how to act. It is clear that multiple actions are needed in many areas and that we need to prioritise and invest more in children, starting early and prioritising children from disadvantaged backgrounds.There are a range of international and national frameworks to guide action, a wealth of dedicated community and professional organisations and individuals and a skilled workforce to help plan, commence and sustain action and to monitor progress.As a society, when we choose to focus we can produce results, such as our success with immunisation. Despite the fiscally constrained environment, NZ has the means to substantially improve child health and wellbeing. It will require reprioritisation and the will, commitment and courage of all our community to acknowledge the issues and negotiate a way forward. This will require a common understanding of the above imperatives for action.How to actNZ already has many components in place. Some actions may take time to negotiate and implement; some changes can be made relatively quickly. There will be some areas in which the course of action is clear, where there is strong evidence of effectiveness or where action is clearly based on what is valued as a nation. However, many areas will not have such clear linear solutions and further dialogue will be required.There are common themes for action, many well expressed in the recent New Zealand Medical Association equity statement37 and highlighted from many previous reports.3,4,7,19,21,30 These broadly include starting with strong nationwide leadership with a voice for children at the highest level of Cabinet.All policies and strategies need child and equity impact assessments. Healthy children's policy requires an equitable fiscal and social policy which includes measures for, and monitoring of, progress on child hardship. Greater co-ordination and integration is required across all policy and service delivery domains. Enhanced effort and integrated approaches are required particularly in the early childhood years and they must be given adequate investment and time to develop and be reviewed.Leaving society's provision for children to philanthropy is ad hoc and insecure, and its failure to provide adequately for all children in need led to the establishment of State welfare programmes last century.38Based on the available evidence an approach based on a universal platform is required to achieve the gains necessary and to enable identification of need.22,39 Proportionate universalism refers to a universal approach but with actions scaled in proportion to need or the level of disadvantage.22A universal platform means that all children and their families are identified at birth, preferably antenatally, their needs and strengths being identified early on, and then appropriate resources or services being made available and accessible, with follow up occurring in a timely manner.16,29,31,32,40RecommendationsThe following 10 recommendations to Government are based on the key themes emerging from a range of local and overseas reviews, which have considered the best ways of achieving optimal child health and wellbeing. While they are ranked by number, an effective and long-lasting solution requires a comprehensive approach, and not cherry-picking of individual recommendations. We recognise that action will require stepped implementation and will require the combined efforts of many, not Government alone.A comprehensive policy framework for children:\r\n Enshrine a whole-of-Government and public sector commitment to children.Through, for example, a Children's Act, a senior Minister for Children within Cabinet, greater investment, child impact assessments, use of the UNICEF Child Friendly Cities Framework by local authorities, and consideration of a core public sector office or Ministry for Children. Develop a comprehensive National Children's Action Plan. Underpinning principles should include UNCROC, te Tiriti o Waitangi, and proportionate universalism. The plan should be cross-sectoral and include a focus on prevention and equity. Establish fair and comprehensive fiscal and social policies for children. This includes a minimum level of support and services for all children and their parents so that they can ‘thrive, belong and achieve.' Establish indicators for child health and wellbeing. Where possible, develop these as targets for service delivery (in addition to immunisation rates).\r\nSpecific health and wellbeing actions:\r\n Build on existing quality improvement and integrating frameworks for children's services. Many activities have already been initiated in other areas of healthcare delivery but there now needs to be a focus on integrating the early life service platforms of maternity, primary care, Well Child\/Tamariki Ora services and early childhood education. Resource effective community-led development initiatives to improve child wellbeing and reduce inequities. Ensure that these are evaluated. Introduce evidence-based measures to protect children from harmful exposures.Starting with maltreatment and violence, the second-hand effects of alcohol misuse and tobacco, and the excessive promotion of unhealthy food. Implement or broaden specific evidence-based measures in important child health areas. Particularly for child nutrition, infant and child mental health, reducing respiratory and infectious diseases, injury prevention, oral health and SUDI prevention. Continue and broaden the programmes which improve home heating and insulation. Both for state and private rental housing. Ensure that the momentum towards all children having free access to primary care services continues and that the additional services that they and their parents need are available at no cost and in a timely fashion. Special effort may be needed to reach Maori and Pacific children, children in the care and protection system, children with disability or chronic conditions, and children from refugee backgrounds. There needs to be a greater focus on child development services, mental health services (infant, child and for parents), special education services, parenting training and support, and other community-based interventional services. The concept of Integrated Family Health Centres may provide an ideal platform for delivering these services.\r\nConclusionNZ has poor and inequitable child health and wellbeing outcomes. Child wellbeing in NZ is one of the most important issues facing the nation. Now is the time to seize opportunities and develop new strategies to improve our child health and wellbeing statistics.Preventing suffering and ensuring the wellbeing of our youngest citizens during their formative years is an ethical issue for our nation, an issue of what we value as a society, and the best investment for a highly productive, innovative and resilient nation for the future.\r\n