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Unicef Innocenti's latest comparative overview of child well-being in rich countries looks like good news for the UK. We have risen up the ranks, now reaching 16th place among 29 countries.1 This mediocre position is worthy of celebration because Unicef's previous report in 2007 was shocking: our overall position was lowest among 21 rich countries.2 We shared this lamentable place with the USA. Indeed many newspaper headlines reflected the recent progress, albeit with one or two examples of scepticism about the notion of measuring child well-being. Children's health policy and systems research has not yet proven its worth to all in the health community, which is trained to believe that the randomised controlled trial is the gold standard of evidence. So it is good to see arguments around this new and important research field, still defining new methods and standards, reaching beyond medical journals to the mainstream press.3
Although ranking countries by health system performance, or any other outcome, can be controversial and often stimulates heated arguments, it effectively focuses attention onto important issues. Indeed the 2007 report provoked debate about important problems for children and families, and crucially prompted investment and research. Unicef UK, for example, enquired further into why children in this country experience such strikingly low well-being, while some children from countries with less economic security have a greater sense of well-being.4 One explanation to this finding lies in the damaging effects of inequality.5 Governments can act to reduce poverty and inequalities directly through redistributive fiscal policy, benefitting those who are most at-risk. However, there is even more that could be done to help children. The harsh effects of poverty can be softened through social protection. For example, Sweden has lower child deprivation rates than other countries of similar wealth (as measured by per capita income) for example Germany, because of their different approaches to supporting vulnerable families, such as those with single parents.6 The UK historically also had fairly good results in poverty reduction and social protection, providing cash and public services to families in need. This has meant that up to 2009, the UK would have had three times the child poverty rate were it not for Government policy on cash transfers, tax credits and public services for children.7 The investment in improving child health and life circumstances paid off and is reflected in the results published in the 2013 report which show modest improvement to the UK's position. Indeed we are now mid-range in the overall ranking, as shown in table 1.1 An important caveat: the data in the report is from 2009–2010, just after the economic crisis began to hit, and when the Coalition government gained power. Any inferences about policy must be confined to the period ending 2010.
A few specific aspects of the report stand out and need urgent attention. First, progress had been made in improving overall child well-being, and in tackling poverty and deprivation, the fundamental social determinants of health. Unfortunately many of these gains will now be reversed as a result of falling incomes, austerity economic policies and cuts to social support. A 2012 report by the Family and Parenting Institute together with the Institute of Fiscal Studies projected that relative child poverty is predicted to increase by 400 000 children between 2010–2011 and 2015–2016 and that half a million children in the UK will live in absolute poverty, as defined by the 2010 Child Poverty Act, within the same period.8 Progress in improving well-being is also likely to reverse.
Second, we should seriously be concerned about how many of our young people are not in education, employment or training. We risk a lost generation of young people growing up at increased risk of mental health problems, substance misuse, crime and long-term unemployment with all the health risks that are associated with these problems. An effective and sustained policy response to this problem is required.
Third, small progress in reducing the percentage of children and young people who are overweight must not breed complacency. Obesity continues to be a major and growing health emergency. We could do better, as shown by detailed information in the report about important proximal determinants of obesity such as food, nutrition and exercise. It is welcome news that the Faculty of Public Health has withdrawn support from the so-called Responsibility Deals with food industry, and that the Academy of Medical Royal Colleges has issued a 10-point action plan which includes a 20% tax on sugary soft drinks and fewer fast food outlets near schools.
Finally, teenage pregnancy continues to be an enormous problem. Parenthood too early in life risks perpetuating cycles of deprivation and disadvantage to subsequent generations. Despite increased effort over recent years, we still lag far behind other countries. We need a fundamental shift in our approach regarding the sexual and reproductive health of young people.
So, what are the main messages of the 2013 Unicef report? In a nutshell: progress has been made, but there remains so much more that could be done, and many of the gains made are now likely to be lost.
What should be done now? How politicians value children is reflected in the choices they make. International comparisons are an important means to raise awareness, stimulate research and drive investment. The Unicef report has important messages for us: until 2010 we were making progress in improving child health and well-being. As child poverty rises and disinvestment in social protection continues, we risk reversing recent gains in well-being.
This need not be inevitable. Politicians have choices. Social protection can save lives. Children are especially vulnerable to the effects of poverty, but countries differ starkly in the protection they give, even in the face of severely challenging economic circumstances. Indeed the equity of distribution of disadvantage in countries might indicate the relative importance they place on the early years. The evidence suggests that the UK disproportionately disadvantages its children and young people. A greater proportion of children, relative to other age groups, is at risk of poverty or social exclusion than adults or the elderly in the UK compared with Sweden for example, as shown in table 2.9
The policy choices that countries make are reflected in the performance of their health systems. For example, poverty, social protection, and generosity of family policies correlate with infant and child mortality, and the UK's low relative position for family policy generosity may partly explain our relatively poor outcome for mortality, among the higher rates in Europe.9–⇓11 By contrast, the UK in common with the Nordic countries has achieved tremendous success in reducing deaths from road traffic through a comprehensive range of enforced policies including legislation, regulation and education, to reduce the morbidity and mortality associated with road traffic.12 Economic, social, and family policy should equally be seen as an essential component to protecting children's lives.
Child rights: a foundation for child health and well-being
What can we do, as children's health professionals? A rights-led approach is a neat way of bringing social justice to the forefront of our efforts to improve child health. The United Nations Convention on the Rights of the Child (UNCRC) describes rights to the highest attainable state of health.13 Although the UK is a signatory of the UNCRC, we have yet to live up to our commitment by incorporating the Convention comprehensively into domestic legislation; doing so would be an important step towards enabling legal challenges to rights abuses. Here is an example of how this could help in practice: nutritional and physical activity environments correlate with child obesity rates,—this is what is meant by the term ‘obesogenic environment’. So when governments, national and local, enable obesogenic environments, this represents a failure to secure children's rights to health.14 We can, and should, advocate for children's rights through meaningful implementation of the UNCRC.
The Unicef report makes an important contribution by deepening our insight into children's lives and their prospects for growing up. We can see the impact that policy made on children's lives through the first decade of the 21st century. We know that progress is possible. Alas, a great deal has changed since then. Anita Tiessen, deputy executive director of Unicef UK, said: “There is no doubt that the situation for children and young people has deteriorated in the last 3 years, with the government making policy choices that risk setting children back in their most crucial stages of development.”15
We are at a pivotal moment in UK child health, when recent gains are likely to be lost. The Unicef report strikes right to the heart of a defining question for our times: what is the duty of the State in protecting and providing the best conditions for nurturing our children? Government policy can foster or hinder children's health, development and well-being. Will we rally behind Professor Marmot's calls for progressive social policies?16 As child health advocates, we should use a rights-based approach to hold the State to account for the policies that shape our children's lives.
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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