The right to health in early childhood

Some 6.3 million children under the 5 years of age died in 2013,¹ mostly from preventable causes and treatable diseases. The rates of child mortality and morbidity have declined significantly in recent years as a result of global and national commitments to child survival. However, mortality rates remain unacceptably high, particularly among young children living in poverty and from marginalized groups in low-income countries.

1. United Nations Children’s Fund (UNICEF) and others, Levels and Trends in Child Mortality: Report 2014 (2014), p. 1. ↩

At least 200 million children under the age of 5 fail to reach their full potential.² According to the Committee on the Rights of the Child, young children’s earliest years are the foundation for their health and development across the life course.³ Their nutritional and health status, as well as the quality of their relationships and social interactions, have life-long implications for their development and health.⁴ Early childhood is the most effective and efficient time to ensure that all children develop their full potential and the returns on investment in early child development are substantial.⁵ Regrettably, children’s right to development has thus far not received the same attention as their right to survival.

2. S. Grantham McGregor and others, “Development potential in the first 5 years for children in developing countries”, Lancet, vol. 369, No. 9555 (6 January 2007), pp. 60-70. ↩
3. General comment No. 7 (2005), para. 6 (e). ↩
4. S. Maggi and others, “International perspectives on early child development”, World Health Organization (WHO), December 2005. Available from www.who.int/social_determinants/ resources/ecd.pdf. ↩
5. A. Lake, “Early childhood development — global action is overdue”, Lancet, vol. 378, No. 9799 (8 October 2011), pp. 1277-1278. ↩

Health, survival and development are not sequential but are intrinsically linked and simultaneous processes. Early childhood programmes should continue to pursue objectives that include survival and health in the short term, but they should more consistently go beyond to embrace healthy development and health throughout life.

The present report focuses on the right to the highest attainable standard of health (“right to health”) and its relationship to the right of the young child to survival and development. These rights are interconnected and indivisible. Their relationship has two key dimensions:
(a) The right to survival and healthy development is central to the enjoyment of the right to physical and mental health throughout life;
(b) The right to health in early childhood includes freedoms and entitlements that are not only essential to immediate survival and health, but also to the healthy development of the child and the adult s/he will become.

Reducing the mortality and morbidity rate among children under 5 years of age has been a focus of the global health community for several decades. More recently, the issue has been given increased attention by the human rights community. Section II of the present report highlights the progress made in reducing under-5 mortality and morbidity and in understanding the human rights dimensions of the issue. While the global health community has increasingly focused on the healthy development of the child, the subject has not yet been given adequate attention by the human rights community. Section III focuses on the close link between the right to health and the healthy development of children under 5 years of age by exploring the meaning and determinants of healthy development, including new scientific understanding of development during the early years. Section IV focuses on the application of the right to health framework to the theme of the report.

The right to health provides a valuable normative and legally binding framework to support the health-related dimensions of early child development. It places a legal obligation on States to guarantee the right to healthy development of children; eliminate discrimination and inequalities that obstruct equitable healthy development; ensure participation of stakeholders by including parents and young children in relevant efforts; devote maximum available resources to the healthy development of children; develop suitable laws and policies, including a comprehensive national plan; and ensure accountability.

Definitions of early childhood vary by country and region. The Committee on the Rights of the Child establishes the limit of early childhood at 8 years of age. This is a common categorization for early childhood used by, among others, the World Health Organization (WHO). In the present report, the Special Rapporteur focuses on children under 5 years of age. This age group is commonly further divided into the neonatal period (0-28 days), infancy (the first year of life) and the preschool years (1-5 years).

Some 17,000 children under 5 years of age continue to die every day, mainly from preventable or treatable causes. In addition, 44 per cent of deaths of children under 5 occur in babies aged 0-28 days. The neonatal deaths result mainly from preterm birth complications (35 per cent), birth asphyxia and trauma (24 per cent) and sepsis (15 per cent).⁶ From 29 days until 5 years of age, the majority of deaths are attributable to infectious diseases such as pneumonia (23 per cent), diarrhoeal diseases (16 per cent), malaria (13 per cent) and HIV/AIDS (3 per cent).⁷

6. UNICEF and others, pp. 14-15. ↩
7. WHO, Global Health Observatory Data Repository. Available from http://apps.who.int/gho/data/ node.main.CODWORLD?lang=en. ↩

Low birth weight, lack of breastfeeding, undernutrition, overcrowded living conditions, indoor air pollution, unsafe drinking water and food and poor hygiene practices are the main immediate risk factors for pneumonia and diarrhoea. However, while such diseases are proximate causes of death and are duly reflected in statistics, poverty and inequalities are the root causes, or underlying social determinants. Poverty increases young children’s exposure to risks such as poor nutrition, violence, inadequate sanitation, lower levels of maternal education, inadequate stimulation in the home, increased maternal stress and depression and, at the same time, limits access to health and other services.⁸ In 2013 the under-5 mortality rate in low-income countries was more than 12 times the average rate in high-income countries.⁹ There are also significant disparities in under-5 mortality and morbidity within countries, driven by poverty, gender and other inequalities. Low levels of literacy and poor access to education among women correlate strongly with high rates of under-5 mortality.

8. S. Walker and T. Wachs and others, “Child development: risk factors for adverse outcomes in developing countries”, Lancet, vol. 369, No. 9556 (13 January 2007), pp. 145-157. ↩
9. UNICEF and others, p. 1. ↩

The reduction of under-5 mortality has been at the heart of the global development and public health agendas. The Millennium Development Goals called for a reduction of under-5 mortality by two thirds between 1990 and 2015 (goal 4). Global commitments such as the Millennium Development Goads have provided impetus for global strategies as well as national plans to accelerate progress, most notably the Secretary-General’s 2010 Global Strategy for Women’s and Children’s Health¹⁰ and Every Newborn: An Action Plan to End Preventable Deaths, issued by WHO in 2014. These documents have helped galvanize international and national action as well provided technical guidance for reducing under-5 mortality and morbidity.

10. The Global Strategy is to be updated in September 2015. ↩

Significant progress has been made in reducing deaths among children under five, from 12.7 million deaths in 1990 to 6.3 million deaths in 2013. However, progress has been insufficient to meet goal 4, particularly in Oceania, sub-Saharan Africa, the Caucasus and Central Asia and Southern Asia.¹¹

11. UNICEF and others, p. 1. ↩

In September 2015, the General Assembly is to adopt a set of sustainable development goals that will replace the Millennium Development Goals as the focus of the international development agenda. At the same time, a new global strategy for women’s, children’s and adolescents’ health is to be launched. The ending of preventable deaths of newborns and children under five is a target of the “zero draft” of the sustainable development goals.¹²

12. Available from https://sustainabledevelopment.un.org/content/documents/7261Post-2015% 20Summit%20-%202%20June%202015.pdf. ↩

Nevertheless, the Special Rapporteur in concerned at what he sees as the “the unfinished business” of goal 4, especially the slow progress in reducing preventable newborn deaths and the alarming prevailing rates of stillbirths.

Reducing under-5 mortality and morbidity is a critical right to health issue. The Convention on the Rights of the Child provides that taking appropriate measures to diminish infant and child mortality is a central aspect of States parties’ obligations in relation to the right of the child to health.¹³ The right to health is therefore closely linked to the right to survive of young children.

13. Article 24.1 and 24.2 (a). ↩

In recent years, the human rights dimensions of under-5 mortality and morbidity have been clarified and the global health and human rights communities have begun to examine the problem through a human rights lens.

In 2013, the Committee on the Rights of the Child adopted general comment No. 15, in which the Committee reiterated the importance of the obligation of States to reduce child mortality and the need to pay particular attention to neonatal mortality, which constitutes an increasing proportion of under-5 mortality.

In its resolution 22/32, the Human Rights Council expressed deep concern about the scale of under-5 mortality and invited WHO to prepare a study on mortality of children under 5 years of age as a human rights concern. The study (A/HRC/24/60) identified the human rights dimensions of under-5 mortality and paved the way for the adoption by the Council of resolution 27/14 on preventable mortality and morbidity of children under 5 years of age as a human rights concern.

In that resolution, the Human Rights Council requested the Office of the United Nations High Commissioner for Human Rights (OHCHR), in close collaboration with WHO and in consultation with other partners, to prepare a report on the practical application of the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity of children under 5 years of age.

The technical guidance (A/HRC/27/31) is a major contribution. It sets out the human rights dimensions of under-5 morbidity and mortality and explains how to apply human rights-based approaches to address the problem. It provides detailed operational guidance for legislative measures, governance and coordination, planning, budgeting, implementation, monitoring and evaluation, remedies and redress and international cooperation. The Special Rapporteur endorses the systematic approach of the technical guidance as a significant step towards the reduction and elimination of preventable deaths of children under 5 years of age.

The global health community has also given attention to the human rights dimensions of under-5 mortality and morbidity and has committed to ground its efforts in human rights. The Secretary-General’s Global Strategy for Women’s and Children’s Health is grounded in global human rights commitments and emphasizes that legislation and policies should be in line with human rights. The new global strategy, which is to replace the existing strategy in the coming months, will call for the integration of human rights in all efforts to improve women’s, children’s and adolescents’ health.

Human rights are also one of six guiding principles of Every Newborn: An Action Plan to End Preventable Deaths. The Action Plan highlights that all planning and programming for reproductive, maternal and newborn health should be guided by principles and standards derived from international human rights treaties. A range of operational tools have also been developed to help States to systematically apply human rights standards in law, policy and service delivery for young children and their caregivers.

The question is often asked in the public health community whether human rights will make a positive contribution in practice. Recent research undertaken by WHO has produced evidence of the beneficial impact that human rights can have on women’s and children’s health in early childhood in the context of initiatives by the executive branch of Government.¹⁴ This research supports the case for human rights to be fully integrated into efforts to improve child health, survival and development.

14. F. Bustreo and P. Hunt and others, Women’s and Children’s Health: Evidence of Impact of Human Rights (Geneva, WHO, 2013). ↩

Nevertheless, there are still very few concrete examples of the actual practical application of a human rights-based approach to child survival and development. In order to make a difference, States should be intentional and explicit about the application of a human rights-based approach in their laws, policies, programmes, budgets and other measures.

The Constitution of WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Development in childhood consists of interconnected domains: physical, cognitive-linguistic and social-emotional. WHO states that the three critical elements of healthy child development are stable, responsive and nurturing caregiving; safe, supportive environments; and appropriate nutrition.¹⁵

15. See www.who.int/maternal_child_adolescent/topics/child/development/10facts/en/. ↩

These elements can be safeguarded through best practices such as planned, safe pregnancy and childbirth; exclusive breastfeeding in the first six months followed by appropriate complementary feeding and responsive parenting; preventive interventions such as vaccines for the treatment of diseases; protection from violence, neglect and abuse; and the reduction of environmental risks.

Young children’s rights to health and development are intrinsically linked in two main ways. First, poor physical or mental health in early childhood is among several interconnected factors that can limit the right to optimal development. About 200 million children fail to reach their developmental potential because of poverty, inequality and discrimination; poor health; poor nutrition, including malnutrition and iodine and iron deficiency; intrauterine growth restriction; a lack of stable, nurturing and responsive environments with learning opportunities; and a lack of safe, supportive physical environments.¹⁶ HIV/AIDS, malaria, violence and maternal depression also cause severe setbacks.

16. R. Jolly, “Early child development: the global challenge”, Lancet, vol. 369, No. 9555 (6 January 2007), pp. 8-9. ↩

Second, the three main domains of early childhood development — physical, social-emotional and cognitive-linguistic — affect health throughout life.¹⁷ All three domains must be given equal attention to promote development in a holistic manner, or healthy development. Research from neuroscience shows how the quality of emotional relationships in early childhood impacts on physical and mental health as well as on morbidity in adulthood. It also shows the detrimental impact of toxic stress and early childhood adversities on the quality of brain architecture and the health status during the life span as developmental stages build on one another. Individual and societal health can be improved through cost-effective and culturally relevant interventions focusing on enhancing children’s emotional and social development, competent parenting and the quality of relationships between children and parents in early childhood.

17. S. Maggi and others. ↩

Despite the very large number of children that fail to reach their development potential, the issue has not been a focus of global attention. It is not explicitly captured by the Millennium Development Goals. In high-income countries, programmes aimed at the promotion of healthy development in early childhood are widespread. However, in low- and middle-income countries, even while awareness of child development is increasing along with the number of relevant policies and programmes,¹⁸ progress is far too slow. While there is a growing consensus that child survival and child development are deeply interrelated, programme financing at the international level has not yet reflected this understanding.

18. P. Engle and others, “Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world”, Lancet, vol. 369, No. 9557 (20 January 2007), pp. 229-242. ↩

The post-2015 development agenda signals a shift from the focus on the survival and health of children under 5 years of age to their survival, health, well-being and development. Sustainable development will require healthy, productive, creative, emotionally competent, confident and capable individuals, meaning that early childhood interventions must focus on development as well as survival.¹⁹ The draft sustainable development goals include new targets, many of which are relevant to early child development. Equity is also an objective and cross-cutting consideration of the sustainable development goals, with important implications for the right to health and early child development.

19. A. Yousafzai and M. Arabi, “Bridging survival and development in the post­2015 agenda: partnerships in nutrition and early child development”, Early Childhood Matters, June 2015, pp. 19-27. ↩

Reinforcing the sustainable development goals approach, the “zero draft” of the global strategy for women’s, children’s and adolescents’ health²⁰ is structured around three goals: survive (ending preventable deaths); thrive (realizing health and rights); transform (comprehensive change for women’s, children’s and adolescents’ health and sustainable development).

20. Available from http://everywomaneverychild.org/images/Global-Strategy_Zero-Draft_FINAL_5-May-2015_copy.pdf. ↩

Children’s right to health includes both their survival and their healthy development. Although ensuring the survival of children is critical, their healthy development is essential to their right to health as well as to other human rights and dignity, both in the short term and throughout their lives. Second, the joining up of these agendas makes practical sense because mortality and morbidity, and obstructed development, among children under 5 years of age share many causes,
can be addressed by the same or similar interventions and can be mainstreamed into existing health and other relevant policies and programmes.²¹

21. P. Engle and others, “Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries”, Lancet, vol. 378, No. 9799 (23 September 2011), pp. 1339-1353. ↩

While welcoming this important paradigm shift towards embracing the right to healthy development, the Special Rapporteur is concerned that in the draft sustainable development goals, and in other documents, there is a tendency to address human rights, including the human rights of children, selectively. For example, while welcoming the proposed goal 5.2 to “eliminate violence against all women and girls in the public and private spheres”,²² he wishes to highlight that no form of violence against children, including boys, should be accepted.

22. See https://sustainabledevelopment.un.org/content/documents/7261Post-2015%20Summit%20-%202%20June%202015.pdf. ↩

Moreover, States should mobilize more political will and resources and facilitate the meaningful involvement of all relevant stakeholders, in particular civil society actors, in the realization of goals and targets of the sustainable development goals related to early childhood.

General comment No. 7 (2005) on implementing child rights in early childhood and general comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health of the Committee on the Rights of the Child embrace a holistic approach to health, survival and development. Building on relevant treaty provisions and on evidence from the public health and scientific communities, the following sections of the report set out a right to health approach to early childhood development.

Infants and young children are holders of all rights enshrined in the Convention on the Rights of the Child as well as other international human rights treaties. The Convention affords special protection for early childhood in recognition of the important and particular challenges facing this age group and the progressive exercise of their rights, in accordance with their evolving capacities.

In this regard, the rights of the newborn, as a rights holder, need to be addressed. Newborn children are too often not considered as deserving the status of autonomous individuals and rights holders and therefore not deserving respect and dignity. Young children, from the first days of their lives, are not only exposed to the environment in which they live but are actively shaping their surroundings by means of their presence and different forms of communication. In paragraph 10 of the recommendations adopted on its day of general discussion on implementing child rights in early childhood, held in September 2004,²³ the Committee on the Rights of the Child underlined that the concept of the child as rights holder is “anchored in the child’s daily life from the earliest stage” (para. 10).

23. Available from www.ohchr.org/Documents/HRBodies/CRC/Discussions/Recommendations/ Recommendations2004.pdf. ↩

Besides defining health, the WHO Constitution also recognized that the highest attainable standard of health is a fundamental human right. The Universal Declaration of Human Rights recognized that everyone has the right to a standard of living adequate for the health and well-being of himself and of his family and that motherhood and childhood are entitled to special care and protection (art. 25). These original international sources of the right to health emphasize that health is a broad concept, covering not only physical but also mental health and not only disease but also well-being, all of which encompass the healthy development of children.

The Convention on the Rights of the Child, the International Covenant on Economic, Social and Cultural Rights and other international human rights treaties recognize the right to health and give rise to binding legal obligations on States parties to respect, protect and fulfil that right.

The treaties set out entitlements and freedoms, assign duties, provide a legally binding framework and demand accountability. They demand particular efforts, mostly by States, to address inequality and discrimination, focusing on the most marginalized young children.

The International Covenant on Economic, Social and Cultural Rights recognizes the links between health, survival and development: article 12 on the right to health obligates States parties to take steps necessary for, among other things, the “provision for the reduction of the stillbirth rate and of infant mortality and for the healthy development of the child”. In other words, in the Covenant, development is part of the right to health. Article 24 of the Convention on the Rights of the Child recognizes the right to health of the child and to facilities for the treatment of illness and rehabilitation of health. This approach underlines that the spectrum of essential health-related services should not be limited to medications and vaccines, but should also include effective public health and psychosocial interventions.

In contrast, the Convention separates the right to health (art. 24) and the right to survival and development (art. 6). However, there is no doubt that these articles are fundamentally linked. For example, article 24 includes a range of obligations that are inseparable from ensuring survival and development, such as diminishing infant and child mortality, providing medical assistance, combating disease and malnutrition, ensuring appropriate pre- and postnatal health care for mothers, providing access to information on child health, developing preventive health care and guidance for parents and abolishing harmful traditional practices. The right to survival and development can only be implemented in a holistic manner through the enforcement of other rights contained in the Convention, such as the right to health.

Other rights relevant to survival and development that are also interconnected and interrelated with the rights to health and life include the rights of young children to be registered at birth; to education; play; a standard of living adequate for the child’s physical, mental, spiritual, moral and social development; adequate housing; adequate nutrition; social security; water and sanitation; and the right to be free from all forms of violence. The present report focuses on the right to health, including aspects of children’s development that fall within the right to health.

Article 3 of the Convention stipulates that in all actions concerning children, the best interests of the child shall be a primary consideration. This provision has wide-ranging implications for policy, including the allocation of resources, as well as decisions concerning individual children.

According to article 12, the child has a right to express his or her views freely in all matters affecting him or her and to have them taken into account. Research shows that a child is able to form views from the youngest age, even when he or she may be unable to express them verbally. Very soon after birth newborn babies can recognize their parents, engage actively in various forms of non-verbal communication and develop strong mutual attachments with their parents or primary caregivers.²⁴ Child-appropriate communication must be ensured to respect the child’s right to information and the right to be heard at all times.

24. General comment No. 7 (2005), para. 16. ↩

States and all relevant stakeholders should adopt an understanding that young children are active participants in interactions with members of their family and community as well as users of health and other services. In this regard, they are entitled to the same respect and dignity as all other members of the family, community and society.

In this section, attention is drawn to specific norms of, and obligations deriving from, the right to health relevant to early childhood development. The vast majority of these standards are also relevant to measures addressing child survival. This approach underscores the benefits of addressing the right to survival and development in an integrated manner.

Health systems, including health-care services and preventive services, should offer, in cooperation with social, child protection, educational and other relevant services, a continuum of care for children and families. Health systems are central to the care of pregnant women, childbirth, postnatal care of the mother and child and the care of young children. Health systems are important not only in relation to specific biomedical interventions, but because they often constitute the only infrastructure that reaches young children, particularly those under 3 years of age, and can therefore initiate and foster health promotion and social service support to promote early child development and prevent risks.²⁵ For example, health visits or growth monitoring sessions can provide an opportunity to incorporate other child development recommendations.²⁶ The health system is therefore often in a good position to take a lead in providing integrated care for young children.

25. P. Engle and others, “Strategies to avoid the loss of developmental potential”, pp. 229-242. ↩
26. Ibid. ↩

A strong health system that is based on such human rights principles as equality and non-discrimination, accountability and participation and that affords access to services for children and caregivers is at the heart of the right to health (see A/HRC/7/11 and Corr.1). The right to health gives rise to obligations on States to ensure the provision of necessary medical assistance and health care to all children, with emphasis on the development of primary health care.²⁷ This includes prevention, promotion, treatment, rehabilitation and palliative care services.²⁸

27. Convention on the Rights of the Child, art. 24.2 (b). ↩
28. Committee on the Rights of the Child, general comment No. 15 (2013), para. 2. ↩

Child-friendly health services, goods and facilities must be available in adequate numbers; geographically and financially accessible as well as accessible on the basis of non-discrimination; culturally acceptable; and of high quality.²⁹ The right to health principles of availability, accessibility, acceptability and quality should therefore be applied in the context of planning and implementation of the main components of the health system: service delivery, health workforce, information, medical products, vaccines and technologies, financing, leadership and governance (A/HRC/21/22 and Corr. 1 and 2, para. 38).

29. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 12. ↩

The importance of primary health care, as expressed in the Declaration of Alma-Ata, adopted at the International Conference on Primary Health Care in 1978, and in article 24 of the Convention on the Rights of the Child must be underlined with regard to health promotion and health-care services for young children.

International human rights law places particular and explicit emphasis on the obligation of States to guarantee a number of relevant health and health-related services. For example, it places an obligation on States to provide appropriate pre- and postnatal health care for mothers³⁰ as well as appropriate services at birth³¹ and to newborns. The Convention on the Rights of the Child has clarified the interventions that should be made available across this continuum³² which are, for the most part, important for optimal child development as well as survival. Children affected by congenital anomalies or malnutrition,³³ chronic illnesses or severe and life-limiting diseases should be referred to specialized paediatric palliative care services, which can be provided in tertiary care facilities, in community health centres and in children’s homes.³⁴

30. Convention on the Rights of the Child, art. 24.2 (d). ↩
31. Convention on the Elimination of All Forms of Discrimination against Women, art. 12.2. ↩
32. Committee on the Rights of the Child, general comment No. 15 (2013), paras. 53-54. ↩
33. Worldwide Palliative Care Alliance (WPCA) and WHO, Global Atlas of Palliative Care at the End of Life (London, WPCA, 2014), pp. 20 and 42. Available from www.who.int/nmh/Global_ Atlas_of_Palliative_Care.pdf. ↩
34. The WHO definition of palliative care for children is available from www.who.int/cancer/ palliative/definition/en/. ↩

Palliative care for young children is an obligatory part of health-care services, beginning when the illness is diagnosed and continuing regardless of whether or not a child receives curative treatment.³⁵ Young children in need of palliative care have the right to receive the necessary physical, social, psychosocial and spiritual care to ensure their development and promote their best possible quality of life.³⁶ Symptom management and pain relief are central to children’s palliative care. Health systems must have adequately trained professionals to assess and treat pain in children of different ages and developmental stages and ensure the availability of paediatric diagnostic procedures and palliative care medicines in paediatric formulations. Palliative care for children must also involve ongoing support to the child’s family throughout the course of treatment and, should the disease be the cause of death, into bereavement.³⁷

35. Ibid. ↩
36. African Palliative Care Association (APCA) and WHO, A Handbook of Palliative Care in Africa (Kampala, APCA, 2010), p. 48. Available from africanpalliativecare.org. ↩
37. Ibid., p. 10 and note 34. ↩

The different elements that form article 24 of the Convention on the Rights of the Child, in particular paragraph 24 (d), (e) and (f), including pre- and postnatal care for mothers; access to education and information on child health and nutrition, advantages of breastfeeding, hygiene and sanitation and prevention of accidents; and the development of preventive health care demonstrate that during the process of adopting the Convention there was a broader understanding of how to promote and protect the health of children.

Since the adoption of the Convention in 1989, there has been increasing evidence of “new morbidities” in childhood related to the understanding that physical and mental health in early childhood are affected by the environment, including relationships within the family, the community and the broader society. This understanding has led to positioning developmental and behavioural issues becoming central components of modern paediatrics.

Modern health systems and modern health policies should not be limited to a biomedical model of addressing separate diseases and managing them with advanced biomedical interventions. Addressing social and other underlying determinants of health by applying modern principles of health promotion, primary care, mental health and integrated health and social services is legally required by the right to health, including in early childhood.

Experts recommend major changes in routine baby medical checks to detect and address social and emotional difficulties, which could be early signs of toxic stress, as a means of reducing many of society’s most complex and costly medical issues, from heart disease to alcohol and drug abuse.³⁸ In addition, some of the evidence-based health interventions that are included in the “zero draft” of the new global strategy for women’s, children’s and adolescents’ health, such as nutrition counselling and “kangaroo” mother care for small babies, can be very useful in assisting main actors adopting a modern approach to health interventions.

38. See, for example, C. Gerwin, “Listening to a baby’s brain: changing the pediatric checkup to reduce toxic stress”, Harvard University Center on the Developing Child. Available from http://developingchild.harvard.edu/resources/stories_from_the_field/tackling_toxic_stress/ listening_to_a_baby_s_brain/. ↩

Currently, primary health care and paediatrics need to be equipped not only with modern lifesaving medicines and vaccines; it is equally important to employ modern interventions that go beyond the biomedical model and to use effective psychoeducational and psychosocial methods based on new research in neuroscience, psychology, developmental paediatrics and child psychiatry. These interventions are not a luxury and should not be seen as such. They need to be supported and funded as effective and essential interventions, and obligatory component of health systems, on a par with the biomedical ones. Therefore, interventions that enhance emotional health and social development from the very start of life should be given priority and special value as investments in human development and global health.

Health workers and other professionals such as social workers have a very important role to play in supporting positive and responsive parenting. States should ensure that there are an adequate number of general practitioners, paediatricians, nurses and other relevant health-care professionals trained to work with children. The Special Rapporteur is concerned that the training and practice of medical doctors, nurses and other health professionals continues to focus predominantly on the biomedical determinants of health. Health-care services and all relevant professionals should be better equipped with relevant knowledge and practical skills to respond proactively to new knowledge about the negative impact of social determinants and early childhood adversities on the physical and mental health of children. For example, nurses and social workers, who visit families with young children should be trained to address issues related to the emotional and cognitive development of children and should be able to provide parents with the knowledge and basic skills necessary for nurturing and responsive parenting and non-violent ways of bringing up children.

Moreover, health and other professionals working with children should be trained on human rights and on early child development and the impact of the quality of relationships on physical and mental health during childhood and throughout life. Paediatricians, all other medical doctors and other relevant health professionals should play a more proactive role in educating families, childcare providers, teachers, policymakers, civic leaders and the general public about the health-related aspects of early child development.

The role of the health sector is given particular attention in the present report. However, as recognized in, among other texts, the Declaration of Alma-Ata, other sectors are also very important for early child health and holistic development. The right to health of young children should be promoted and protected through sustainable and transparent implementation of the principle “health in all policies”.

The right to health includes more than health care; it is also the right to the underlying determinants of health, such as nutrition; protection against violence; healthy and safe environments, including in the family environment and local community; health-related information and education; safe drinking water; adequate sanitation; and adequate housing.³⁹ These and other social determinants of health have an impact on the development of the child. Indeed, the environment is a fundamental determinant of the health and well-being of the child and of the adult.

39. International Covenant on Economic, Social and Cultural Rights, art. 12.2; Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 11. ↩

Nutrition, an underlying determinant of the right to health, is essential to children’s health, survival and development. Adequate nutrition begins in utero, since the nutritional status of woman shortly before and during pregnancy can affect the health and healthy development of the child after birth.

After birth, adequate nutrition can be supported by the initiation of breastfeeding, exclusive breastfeeding for six months and continued breastfeeding through to the second year of life,⁴⁰ nutritional supplementation and ensuring the availability of and access to healthy and culturally appropriate diets for infants and young children, including by improving food security. Infant and young child feeding is a key area in improving child survival and promoting healthy growth and development. The first two years of a child’s life are particularly important, as optimal nutrition during this period lowers morbidity and mortality, reduces the risk of chronic disease and fosters better development overall.⁴¹

40. WHO and Commission on the Social Determinants of Health, Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health (Geneva, WHO, 2008), p. 50. Available from http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf?ua=1. ↩
41. WHO, “Infant and young child feeding”, Fact Sheet No. 342, February 2014. ↩

Health care and other services can also play an important role in supporting adequate nutrition through provision of information to pregnant women and families on optimal nutrition, screening and provision of supplements. Breastfeeding remains one of the most effective interventions in reducing child mortality and morbidity. Therefore, ensuring that mothers have an enabling and supportive environment to breastfeed their children is crucial. This includes adequate maternity protection and protection from inappropriate marketing of breast milk substitutes in public and health-care settings.

In this connection, the importance of States’ commitments under the global targets for improving maternal, infant and young child nutrition must be underlined. The targets are crucial to establishing priority areas for action and catalysing global change.⁴²

42. WHO, Global targets 2015 to improve maternal, infant and young child nutrition. Available from www.who.int/nutrition/global-target-2025/en/. ↩

In recent years, research has investigated and highlighted links between exposure to violence and other adverse experiences and long-term health and development problems.⁴³ Violence includes “all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse”.⁴⁴ Violence most often occurs in the home, but it can also occur in the community.⁴⁵ Prolonged exposure to various forms of violence and insecurity can result in toxic stress. For young children, the effects of family violence can have particularly negative consequences given their almost total reliance on family members for protection and support.

43. WHO, Addressing Adverse Childhood Experience to Improve Public Health: Expert Consultation. 4-5 May 2009. Available from www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_experiences/ global_research_network_may_2009.pdf. ↩
44. Committee on the Rights of the Child, general comment No. 13 (2011), para. 4. ↩
45. G. Darmstadt, “Progress and challenges in ensuring healthy births and babies”, Early Child Matters, June 2014, p. 14. ↩

Violence and toxic stress can have a serious detrimental impact on children’s health.⁴⁶ Addressing violence has intergenerational benefits since children who have not experienced violence are less likely to act violently in childhood and as adults.⁴⁷

46. Committee on the Rights of the Child, general comment No. 13 (2011), para. 15 (a). ↩
47. Ibid., para. 14; Paulo Sérgio Pinheiro, Independent Expert for the Secretary-General’s Study on Violence against Children, World Report on Violence against Children (Geneva, 2006), pp. 63-66. ↩

In 2011, the Committee on the Rights of the Child adopted general comment No. 13 on the right of the child to freedom from all forms of violence, which highlights a wide range of measures that States parties must take to address violence against children. Endorsing the approach taken by the Committee in the general comment, the Special Rapporteur wishes to emphasize the importance of a zero tolerance approach to any form of violence against children.

Parents or other primary caregivers play a central role in promoting healthy child development and strongly influence children’s socialization. Early childhood development can be influenced by maternal nutrition, maternal mental and physical health, parental stress, depression and parenting styles. Although the role and rights of mothers are often — and rightly — given emphasis, the role and rights of fathers are also very important,⁴⁸ as are those of grandparents and other members of the extended family.

48. G. Barker, “Why men’s caregiving matters for young children: lessons from the Men Care campaign”, Early Childhood Matters, June 2015, pp. 51-53. ↩

It should be noted that families take various forms and arrangements (see A/HRC/29/40)⁴⁹ and recognition of this diversity is crucial to ensure the protection and promotion of the rights of all of children and all parents, including the right to health, without discrimination of any sort.

49. See also Committee on the Rights of the Child, general comment No.7 (2006), para. 15. ↩

The Special Rapporteur endorses efforts made at all levels of decision-making and policy implementation that support families, as the family is where children can best thrive. However, he recalls that children are all too often exposed to mental, physical and sexual violence within families.

Bearing this in mind, the Special Rapporteur urges all stakeholders to continue to support families with a variety of mechanisms and services aimed at strengthening their resilience, encouraging competent parenting and developing skills to address the challenges of bringing up children in responsive and non-violent ways. To that end, States should adopt legal and policy measures to eliminate all forms of violence against children, including banning corporal punishment in all settings, and prevent the perpetuation of a cycle of violence within families, communities and societies while strengthening community-based family support services.

In this connection, it is of special importance that all stakeholders understand the harmful effects of institutional care in early childhood; it is a form of violence against young children. The Special Rapporteur therefore urges all stakeholders to continue to implement the Guidelines for the Alternative Care of Children (General Assembly resolution 64/142, annex) and to expedite the process of eliminating institutional care for children under 3 years of age. Furthermore, he calls for recognition of the detrimental effects of institutional care on the health and development of all young children and for the adoption of a common understanding that institutional care should not be accepted for children under 5 years of age.

The Special Rapporteur is also concerned about families and parents at risk and in vulnerable situations who are exposed to multiple forms of stress because of poverty, social exclusion and discrimination, including families who migrate, are internally displaced persons or refugees or belong to marginalized racial or ethnic groups and parents who use drugs or have mental health problems. The solution is not to blame parents and take their children away from them. It is first the responsibility of States to address discrimination and provide adequate support services so that risks are eliminated and the basic rights and needs of children are protected within the family environment.

For instance, mental health issues or drug use are not in themselves indicators of bad parenting, but rather a signal of a potential situation of risk. Parents with mental health challenges or with drug dependency issues who have young children should have access to appropriate services, such as psychosocial interventions or harm reduction services that encourage the development of healthy and nurturing relationships of parents with their children. Barriers to realizing the right to health of families at risk include the criminalization of parents who use drugs as well as policies that pursue the revocation of custodial rights of those with mental health issues. Criminalization and penalization drive families at risk, including parents who are drug dependent or have mental health problems, away from health and social services for fear of arrest and loss of their children.

Inequalities and discrimination obstruct equitable healthy development and educational attainment among young children from marginalized groups, including persons living in poverty, minority and indigenous groups, the girl child, persons with disabilities, persons in underserved areas such as rural populations, refugees, internally displaced children and children living in areas affected by conflict. Inequalities and discrimination ultimately contribute to health and other inequalities later in life and to the intergenerational transmission of disadvantage.⁵⁰

50. WHO and Commission on the Social Determinants of Health. ↩

The twin fundamental human rights principles of equality and non-discrimination mean that States have legally binding human rights obligations to immediately address the healthy development of young children from marginalized groups so they can enjoy the right to health on the basis of equality. This obligation corresponds to the three pillars of the process of progressively achieving universal health coverage — expand priority services, include more people and reduce out-of-pocket payments — and must be addressed when providing services for young children and their families from disadvantaged groups.⁵¹ The collection and analysis of disaggregated data are necessary to reveal which groups are disproportionately affected.⁵² Outreach and other programmes are required to ensure that disadvantaged children enjoy the same access to health care and other relevant services as other children (A/HRC/7/11 and Corr.1, para. 42).

51. WHO, Making Fair Choices on the Path to Universal Health Coverage: Final Report of the WHO Consultative Group on Equity and Universal Health Coverage (Geneva, 2014). ↩
52. Committee on the Rights of the Child, general comment No. 7 (2005), para. 36. ↩

The following paragraphs address some of the groups of children that are marginalized in the context of early child development as well as the human rights obligations of States to address discrimination and its root causes.

Gender biases within families give rise to a range of inequalities that obstruct the optimal development of the girl child. Where gender inequalities persist, boys may receive greater medical attention and girls may be vulnerable to discriminatory feeding patterns.

International human rights law places particular emphasis on the responsibility of States to address discrimination against women and girls and ensure that they enjoy their rights on the basis of equality with men and boys. Among other actions, States must ensure that national law provides a robust framework for gender equality and non-discrimination. In the context of early child development, policies and programmes must pay particular attention to redressing discrimination and to equality. For example, parenting programmes should be gender sensitive⁵³ and States should make particular efforts to address any discrepancy in educational attainment between girls and boys.

53. WHO and Commission on Social Determinants of Health, p. 56. ↩

The Special Rapporteur wishes to highlight that the healthy development of boys is an important issue and should also be addressed. In many cultures boys are not allowed or encouraged to express their emotions, which results in the adult male population being more prone to violent and self-destructive behaviour. This inhibition relates to gender stereotyping that is harmful for both girls and women, boys and men.

Despite being more vulnerable to health and developmental risks, young children with disabilities are often overlooked in mainstream programmes and services designed to promote health to ensure child development. They also often do not receive the specific support required to meet their needs in accordance with their rights. Children with disabilities and their families are confronted with barriers that include inadequate legislation, policies and services, negative attitudes and a lack of accessible environments. Children with developmental disabilities, including intellectual disabilities and autistic-spectrum conditions, are still suffering from outdated approaches in many countries such as institutionalization and excessive medication.

Early intervention services for children with disabilities should follow a human rights-based approach, including provisions of the Convention on the Rights of Persons with Disabilities. Governments should ensure that all young children with disabilities grow up in families and that they and their families receive all necessary services to remove barriers and promote their rights in the same manner that the rights of children without disabilities are promoted. Practices based on institutional care and overuse of biomedical interventions for young children with developmental disabilities should be abandoned as they are outdated and often violate basic rights and freedoms.

“Intersex” refers mainly to physical aspects of the body and includes a wide range of natural body variations that do not conform to prevailing notions of male and female bodies.⁵⁴ Deeply rooted stereotypes around gender dichotomy and medical norms about male and female bodies have led to the establishment of a medical practice of routine interventions and surgeries on intersex people, including irreversible genital surgery and sterilization. These interventions are not always necessary on medical grounds and are often not performed with the informed consent of the persons concerned. Moreover, medical classifications currently codify intersex characteristics as pathologies or disorders.⁵⁵

54. OHCHR, Fact Sheet: “LGBT rights: frequently asked questions”, 2013. ↩
55. Commissioner for Human Rights, Council of Europe, Issue Paper: “Human rights and intersex people”, 2015. ↩

These practices, if performed without due consideration for the best interests and evolving capacities of young children, can have detrimental, long-lasting effects on their health and well-being; violate their basic rights to physical integrity, privacy and autonomy; and may amount to ill-treatment or even torture.⁵⁶ In addition, the sex assigned at birth becomes a legal and social factor, often permanent or difficult to change, that will determine the life and development of the child and affect his/her right to develop a personal identity.

56. Joint statement by a group of United Nations and international human rights experts on the occasion of the International Day against Homophobia, Biphobia and Transphobia, “Discriminated and made vulnerable: young LGBT and intersex people need recognition and protection of their rights”, 13 May 2015. ↩

On the basis of international human right law and standards,⁵⁷ States should prohibit unnecessary medical or surgical treatment during infancy or early childhood in order to guarantee the bodily integrity, autonomy and self- determination of the children concerned.

57. See, for example, documents CRC/C/CHE/CO/2-4, CAT/C/DEU/CO/5, E/C.12/DEU/CO/5, CEDAW/C/CRI/CO/5-6, CRPD/C/DEU/CO/1, A/HRC/29/23, A/HRC/22/53 and A/64/272. ↩

International human rights law recognizes that individuals and groups have the right to participate in decision-making processes that affect their rights.

States have a legally binding obligation to ensure the participation of rights holders in priority-setting; legislative and policy development, implementation, monitoring and evaluation; and accountability for the realization of the right to health and the holistic development of the young child. All segments of the population, including the most marginalized, must be empowered to participate (A/HRC/27/31, paras. 28-30). States must create an enabling environment for participation, for example by enhancing the knowledge and awareness of stakeholders, including the parents of young children.

In the context of children under 5 years of age participation means two separate things. First, it means ensuring that parents, or other representatives, are able to access the information required for them to develop an informed opinion about the child’s health status and potential interventions and to participate thoroughly in decision-making processes that affect their children’s health, survival and development.

Second, in accordance with their evolving capacities, young children, including infants, have a right to express their views freely in all matters affecting them and to have these views taken into account.⁵⁸ Infants and very young children have particular forms of expression, which, because of their age, are sometimes non-verbal. Young children should be active participants in the promotion, protection and monitoring of their rights within the family, the community and society,⁵⁹ in accordance with their evolving capacities. States must therefore ensure the necessary institutional arrangements for the participation of young children and their caregivers.

58. Convention on the Rights of the Child, art. 12. ↩
59. Committee on the Rights of the Child, general comment No. 7 (2005), para. 14. ↩

Accountability is essential if the right to health is to be more than window dressing. International human rights law provides a legal basis for accountability. The three primary components of accountability are monitoring, review and redress. Multiple administrative, political and legal accountability processes have a role to play in guaranteeing the right to health, including survival and development, in early childhood. These mechanisms should provide accountability for the protection of the rights to health and healthy development in early childhood in national policies, programmes and plans and in the delivery of services and enable individuals and groups to seek redress where this has not happened.

Accountability processes provide an opportunity for duty bearers to explain what they have done and for adjustments to be made where human rights have not been respected and protected. They equally provide rights holders with an opportunity to engage with duty bearers in relation to the promotion and protection of their rights and to seek redress where violations have occurred.

In recent years, the importance of accountability for the health of young children has been increasingly recognized by the international community, including in the Global Strategy on Women’s and Children’s Health and in the final report of the Commission on Information and Accountability for Women’s and Children’s Health.⁶⁰

60. Keeping Promises, Measuring Results, 2011. Available from http://www.who.int/topics/ millennium_development_goals/accountability_commission/Commission_Report_advance_ copy.pdf. ↩

The potential of individuals, communities and civil society to act as key forces for change in health outcomes has received increasing attention in recent years, particularly in relation to accountability. Experiences of citizen accountability include the use of scorecards, social audits and new information technologies for social monitoring. Many civil society actors inform citizens about their rights and the services they are entitled to and conduct third party monitoring and analyses. Budget analysis, public expenditure tracking and absenteeism surveys to monitor attendance of service providers in health facilities are other examples. It has been shown that responsiveness and transparency on the part of Governments are enhanced when citizen accountability is carried out effectively and their engagement has become central to implementing civil society recommendations for government priority-setting.

Accountability should include the development of new measures to monitor the development of young children, at the level both of the individual and the population. Therefore, the selection of indicators and the systematic gathering of data, disaggregated where appropriate, are not only essential to monitor progress but also to support accountability.

The Convention on the Rights of the Child provides a comprehensive normative and legally binding framework to address the right to health and the holistic development of the young child. States have legally binding obligations to adopt and implement laws, regulations, policies, budgetary measures, programmes and other initiatives to ensure the respect, protection and fulfilment of the right to health, including healthy development, in early childhood.

The right to health is subject to progressive realization and resource constraints.⁶¹ This means that the right to health does not have to be realized immediately; rather, States must take effective and targeted measures towards the progressive realization of the right to health, including for the young child. This is similar to the concept of “progressive improvement” found in the Declaration of Alma-Ata. Progressive realization and resource availability also acknowledge the differences between high- and low-income countries.

61. International Covenant on Economic, Social and Cultural Rights, art. 2.1; Convention on the Rights of the Child, art. 4. ↩

However, given the overall low priority given to early childhood development reflected in low levels of funding for programmes, especially for children under 3 years of age, States should do their utmost to scale up investment in early childhood health and development.

Progressive realization has a number of implications. For example, States must have a national plan for the right to health and development in early childhood, the lead for which should be taken by the health authorities, especially for children under 3 years of age. In addition, coordinated governance across health, education and social protection policies, plans and programmes should be enhanced at both national and local levels.

Another implication of progressive realization is that there must be appropriate indicators and benchmarks to monitor progress in the realization of the right to health in early childhood.⁶² Indicators must be disaggregated on suitable grounds, such as sex, socioeconomic status, age and ethnicity, to reveal whether the right to health is being realized on the basis of equality and non-discrimination. In recent years, there has been progress towards the development of a set of globally accepted measurements and indicators on child development that could be used to monitor progress as well as for planning purposes in different countries.⁶³ Progress on this matter should be accelerated.

62. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), paras. 57-58. ↩
63. P. Engle and others, “Strategies for reducing inequalities”. ↩

Certain “core obligations” are not subject to progressive realization and must be implemented immediately.⁶⁴ Core obligations include: (a) elaboration of a comprehensive national plan for the right to health, including development, in early childhood; (b) non-discriminatory access to health and other relevant services; (c) equitable distribution of health and other facilities for the right to health in early childhood; and (d) access to a minimum “basket” of health-related services and facilities (A/HRC/7/11, para. 52).

64. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), paras. 43-45. ↩

The right to health gives rise to an obligation of international cooperation and assistance.⁶⁵ High-income States have a duty to provide cooperation and assistance for the right to health in low-income countries. There is a particular obligation to assist with respect to core obligations. Low-income countries also have an obligation to seek appropriate cooperation and assistance.

65. International Covenant on Economic, Social and Cultural Rights, art. 2.1; Convention on the Rights of the Child, art. 4. ↩

As the global health agenda moves from a survival to a survival and development agenda, the Special Rapporteur urges high-income States to support low-income States in their endeavour to enhance the promotion and protection of the right to health in early childhood, including its developmental dimensions.

States, as primary duty bearers under international human rights law, are under a duty to protect the right to health by ensuring that the actions of third parties contribute to and do not jeopardize it.⁶⁶ For example, States must support and assist, to the maximum their extent of available resources,⁶⁷ parents and caregivers to care for children and secure the living conditions necessary for their health and optimal development; and protect child victims of violence and witnesses and investigate and punish those responsible for its occurrence.

66. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 51. ↩
67. Convention on the Rights of the Child, art. 4. ↩

It is also the obligation of States “to adopt legislation or to take other measures ensuring equal access to health care and health-related services provided by third parties.”⁶⁸ In relation to early child development and survival, States should introduce into domestic law, implement and enforce the International Code on Marketing of Breast-milk Substitutes.⁶⁹

68. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 35. ↩
69. Committee on the Rights of the Child, general Comment No. 15 (2013), para. 44. ↩

The health, survival and healthy development of young children must be placed at the centre of the implementation of post-2015 agenda and other global, regional and national commitments and actions.

The right to survival as a central element of children’s health is now widely recognized as a human rights and public health concern and concerted efforts by all stakeholders have resulted in a significant reduction of preventable infant and under-5 mortality. Despite this progress, in many countries and among disadvantaged groups of the population, mortality and morbidity rates in early childhood remain unacceptably high. More needs to be done to eliminate deaths from preventable causes in early childhood.

Beyond sheer survival, children have a right to thrive, develop in a holistic way to their full potential and enjoy good physical and mental health in a sustainable world. The right of young children to healthy development is crucial to promote and protect the right to health throughout life as well as to foster sustainable human development; however it has not yet received adequate attention.

Investing in healthy development, good mental health and emotional well-being in early childhood through effective public health, and psychosocial and psychoeducational interventions is not a luxury. The value of these interventions may be equal to the value of lifesaving essential medicines and vaccines, as they protect children from the detrimental effects of violence and other early childhood adversities.

Momentum now exists towards a new decade of focus on child development that builds on the progress made on child survival and takes it to the next step so that children can thrive, develop to their full potential and thus contribute to healthier societies and sustainable development.

States should be more intentional and explicit about the application of a human rights-based approach in their laws, policies, programmes, budgets and other measures. Good practices in applying human rights principles to addressing child survival and development worldwide should become the rule rather than the exception.

In this connection, the Special Rapporteur urges Governments:
(a) To address the youngest children, especially newborns and infants, as rights holders and to join forces with all relevant stakeholders to achieve a breakthrough by significantly reducing mortality and morbidity rates among newborns;
(b) To adopt a broader approach when investing in children’s health by effectively addressing the detrimental impact of violence and early childhood adversities;
(c) To introduce legal and policy measures that promote effective interventions to improve the quality of relationships between young children and parents, to promote the competence of parents and to equip and support them with skills for bringing up young children in a non-violent way;
(d) To ban corporal punishment of children in all settings, including in families, and to continue informing parents, policymakers and the general public that corporal punishment of children as well as all other forms of violence are against human rights and have serious detrimental effects on the health and development of young children;
(e) To initiate, support and sustain changes in child health-care policies and services so that the right of young children to healthy development is fully recognized;
(f) To promote the development and practical application of appropriate indicators and benchmarks to monitor progress in the realization of the right to health in early childhood, including in the areas of emotional and social development;
(g) To equip primary health-care and paediatric services not only with modern lifesaving medicines and vaccines, but also with knowledge and effective and culturally appropriate interventions based on research in neuroscience, psychology, developmental paediatrics and child psychiatry;
(h) To train health and other professionals working with children on human rights, including on early child development and the impact of quality relationships on physical and mental health during childhood and throughout life;
(i) To disseminate the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable mortality and morbidity of children under 5 years of age to all relevant government sectors and ensure its systematic application in the development, implementation and review of laws, policies, budgets and programmes;
(j) To continue to implement the Guidelines for the Alternative Care of Children and to eliminate long-term placement of young children in institutional care;
(k) To eliminate institutional care for children during the first five years of life and promote investments in community-based services for families at risk, including for families living in poverty and those with young children with developmental and other disabilities;
(l) To comply fully with the standards contained in the Convention on the Rights of Persons with Disabilities and eliminate outdated practices based on institutional care and excessive medication of young children with developmental and other disabilities;
(m) To prohibit discrimination against intersex people, including by banning unnecessary medical or surgical treatment, and adopt measures to overcome discriminatory attitudes and practices through awareness-raising, training for public officials and medical professionals and the elaboration of ethical and professional standards that respect the rights of intersex persons, in consultation with intersex people and their organizations;
(n) To put an end to the criminalization and penalization of parents in situations of risk and ensure their access to appropriate services and child-friendly treatment options.

In addition, the Special Rapporteur recommends that other stakeholders:
(a) Step up efforts to significantly reduce mortality and morbidity rates among newborns;
(b) Help disseminate the technical guidance to reduce and eliminate preventable mortality of children under 5 years of age and provide necessary technical assistance to States for its application;

The Special Rapporteur also recommends that paediatricians, other medical doctors and health professionals play a more proactive role in educating families and other key actors about the health-related aspects of human rights of young children, including their right to healthy development.