CHILD HEALTH PRIORITIES ASSOCIATION
28 March 2020
Minister of Health, Dr Zweli Mkhize [email protected]
Acting Director General: National Department of Health, Dr Anban Pillay
Deputy Director-General: HIV & AIDS, TB and Maternal, Child and Women's Health (MCWH),
Dr Yogan Pillay
Dear Dr Mkhize,
Call to action to safeguard child health services and for a more child-sensitive health system
On behalf of the Child Health Priorities Association and our affiliated members, we wish to thank you and your team for the leadership during this unprecedented crisis facing our country.
While we recognize and are cognizant of the enormity of the situation that bears down on our already overstretched health system, we wish to raise our concerns and objections to the further marginalization of child health services.
In our call to action to safeguard child health services during, and post-covid-19, we have put forward a few possibilities of how we may be of service and assistance to the National and Provincial Departments of Health. Together, we would like to ensure that children, the future of South Africa, are not put at additional health risk nor that we fail the needs of children, our most vulnerable sector of the population.
We trust that our submission is received in the constructive intent with which it is made. We look forward to continuing to support the National Department in serving the needs of children and to protect their health rights, especially during this crisis.
Please call upon us so that collectively, we can safeguard child health services and the rights of children in South Africa.
Yours sincerely,
Chantell Witten
Chairperson CHPA 2020-2021
cc National Department of Health Ministerial Committee for the Morbidity and Mortality of Children under 5 years (CoMMiC)
South African Civil Society for Women’s, Adolescents’ and Children’s Health (SACoWACH)
University of Cape Town/Children’s Institute
University of Pretoria/Centre for Child Law
Where are the children? A call to safeguard children in the health system’s response to COVID-19
Motivation
Given the unprecedented scale of the COVID-19 situation, we recognize and are cognizant of the necessity for the health system response to COVID-19 to prioritise the needs of adult patients but we are resolute that it should not do so at the expense of children.
We have received reports that resources are currently being diverted away from paediatric services to support adult care, such as designating paediatric wards as adult wards, and the redeployment of nursing staff from paediatric to adult services. This is likely to seriously undermine children’s rights to health, care and survival.
While data from China suggest that children may be less vulnerable to COVID-19 infection than adults, experience less severe symptoms, or be asymptomatic carriers of the virus, it is difficult to predict how COVID-19 will impact on children in South Africa given the high proportion of children whose immune systems are compromised by exposure to HIV (21%), stunting (27%) and TB. In addition, South Africa’s children are more likely than adults to be living in poverty (59%), without access to water on site ((30%) and in overcrowded households (18%).
It is therefore not surprising that lower respiratory tract infections and acute diarrhoea remain the leading cause of child deaths in hospital (27% and 26% respectively), and that 50% of hospital deaths are associated with malnutrition.
These pre-existing vulnerabilities are likely to intensify under conditions of lockdown and the COVID-19 pandemic which is likely to further compromise children’s access to food, water and sanitation, and increase their exposure to domestic violence.
In some provinces, paediatric services are already stretched to capacity coping with the annual diarrhoea and pneumonia surge season and the confluence with the COVID-19 pandemic has the potential to create a perfect storm with devastating consequences for child health at a time when there is an annual increase in demand for paediatric services.
43% of South Africa’s children live with single mothers, and a further 20% live in the care of relatives (mostly grandmothers). COVID-19 is likely to have a profound impact on these already fragile households. It is therefore essential for health to put a system in place to identify and support children of adult patients of COVID-19.
The State has a responsibility to prioritise and uphold children’s right to health care services given their acute vulnerability in fragile, emergency situations, and to put measures in place to safeguard the provision of these essential services in line with the United Nations Committee on the Rights of the Child’s General Comment on the Right to Health, and WHO recommendations for the care and protection of children in disaster settings.
Recommendations to safeguard child health and well-being during the COVID-19 pandemic:
There is an urgent need to safeguard children within the health system’s response to COVID-19, and to minimise disruptions to essential paediatric and child health services, including immunisations, HIV treatment and chronic care, during and post lockdown and for longer if the need for further lockdowns persist in South Africa.
In a spirit of solidarity, we therefore offer our support to our colleagues in the Department of Health in developing a clear plan of action to safeguard children infected or affected by COVID-19 within the health care service, and to mitigate the effects of the COVID-19 pandemic on essential child health services
This plan should address the following areas:
A. Maintain routine essential services
1. Acute care needs to adapt to include children with COVID. Paediatric beds should not simply be given to adult services until we have a better idea of the impact of COVID on children in South Africa and their need for inpatient care. Bed occupancy in paediatric wards varies across provinces and in response to seasonal fluctuations in disease – higher in regional centres, lower in district hospitals, with neonatal wards particularly prone to overcrowding. While bed occupancy may be lower in certain children’s wards, resources are already thinly stretched in others. Decision makers therefore need to remain sensitive to regional and seasonal fluctuations in the paediatric burden of disease, put in place plans to sustain routine paediatric care, and have a clear back-up plan to re-assign beds to paediatric patients when required, if beds have already been annexed.
2. Neonatal services are already limited and must NOT be drained of significant capacity, especially in relation to nursing staff, as resources are diverted to meet adult needs. In addition, mothers who have COVID-19 will need to be separated from those who are not infected and this calls for additional spaces and staff.
3. Children attending health services must be protected from exposure to COVID-19 – through screening on presentation, separation of child and adult services, and separation of COVID-infected children from other children in inpatient settings.
4. Chronic and ambulatory care can and should be modified. Strategies need to be found to be found to ensure the safe delivery of contraceptives, antiretroviral therapy and other essential chronic medication during lockdown, and to re-establish routine care as soon as possible. For example, the provision of medicines for longer periods (≥ 2 months), less frequent health centre visits and delivery to households. 5. Childhood immunisation services are likely to be disrupted due to decreased demand and access (due to lack of transport, diverted resources, etc.). There must be focused strategies to ensure catch up of missed immunisations when it is feasible to do so.
6. Communication and health care messaging needs to extend beyond measures to prevent the spread of COVID-19 and incorporate key messages around child health, safety and nutrition - including the benefits of breastfeeding and food hygiene - injury prevention (and the risks associated with bleach and hand sanitisers), the need to make up missed vaccinations following the lockdown, and how to access chronic medicines and contraceptives during the pandemic.
B. Safeguard children infected or affected by COVID-19
In addition, it is essential to put measures in place to address to safeguard children infected by COVID-19 or children whose primary caregivers have been infected/admitted. This should include:
1. The availability of standard treatment guidelines for children with or suspected of having COVID-19 including operational guidelines for a tiered health system, and clear referral criteria to ensure access to the appropriate level of care based on the acuity of illness.
2. On admission of all adult patients, routine questions about children and childcare arrangements should be included to identify children who may be in need of care and protection.
3. The provision of appropriate child-centred care, ranging from basic symptomatic and supportive care, through to varying degrees of respiratory support and intensive care.
4. A system is in place to enable children to access family care and support even when separated from their families – whether as child patients, or children of adult patients – for example, using mobile technologies to maintain contact.
5. Psychosocial support for infected children and family members including access to child- friendly information about COVID-19 – its symptoms, treatment, and prognosis - and tools to help children cope with the associated fear, anxiety, grief and loss.
6. Measures to safeguard children within the health care service, and clear referral systems to link children with social or psychological needs to appropriate services (DSD and allied services within Health) for ongoing care or support. Increased capacity in these partner services will be required.
C. Care for health care workers and their families
Finally, we are mindful that COVID-19 is potentially devastating for health care workers and their families, and that the national lockdown has impacted on access to schools, early childhood development centres and childcare. Measures therefore need to be put in place to:
1. Provide psychosocial support and debriefing for health professionals on the frontline and to prevent, identify and respond to signs of anxiety, burnout and post-traumatic stress disorder.
2. Provide access to care, health and safety of the children of health professionals including alternative care arrangements, psychosocial support, counselling and safeguarding measures should their parents become infected.