THEMATIC PAPER 1 Universal floors for better health and well-being for all children and adolescents

WORKING TOGETHER FOR BETTER HEALTH AND WELL-BEING Promoting Intersectoral and Interagency Action for Health and Well-being in the WHO European Region High-level Conference 7–8 December 2016, Paris, France

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CONTENTS

Page

Acronyms ...... iv

Introduction ...... 2

Providing social protection floors and facilitating intersectoral collaboration ...... 3 Make universal social protection a priority for a healthy future for all ...... 3 Collaborate across sectors to deliver on safe pregnancy and neonatal survival ...... 3 Coordinate across sectors to improve antenatal and children’s health services ...... 4 Health-promoting nurseries and pre-schools for all children ...... 4 Adequate resources and income support for all families and young people ...... 5 Ensure that adequate parental leave is available to all to give children the best start in life5 Ensure proper living conditions – essential for children’s health and well-being ...... 6 Take intersectoral action to identify children at higher risk early ...... 6 Ensure intersectoral information-sharing, referral procedures and follow-up ...... 7

References ...... 8

page iv

Acronyms

ILO International Labour Organization IMF International Monetary Fund SDG Sustainable Development Goal Universal social protection floors for better health and well-being for all children and adolescents page 1

Executive summary This Thematic Paper on universal social protection floors for better health and well-being for all children and adolescents was produced to support and inform the discussion at the high-level conference on Working Together for Better Health and Well-being: Promoting Intersectoral and Interagency Action for Health and Well-being in the WHO European Region, held in Paris, France on 7–8 December 2016.

It is well understood that countercyclical social protection is an important protector against poverty, plays a key role in the health and well-being of families, and is a determinant of the education, health and life satisfaction of children and adolescents. Access to adequate social protection, which includes universal health coverage and basic income security for all children, adolescents, their families and communities, is essential, as is access to nutrition, education, care and any other necessary goods and services based on fair funding mechanisms.

An adequate mix of interventions helps create the family conditions that allow children and adolescents to thrive. This starts before birth and continues throughout the life-course, including, but not limited to: joined-up community-based prenatal and antenatal services and programmes; quality nursery and day-care programmes that support early childhood development and allow parents to return to work; labour market policies that provide adequate income for families and (in particular) support young people’s transition from education to employment; maternity, paternity and parental leave for all families; decent living conditions; and measures to identify children at risk and ensure referral and follow-up procedures being in place.

Enhancing social protection is also integral to achieving the 2030 Agenda goals and targets related to the eradication of poverty (Sustainable Development Goals (SDGs) 1 and 3), promotion of gender equity (SDG 5), promotion of decent work and economic growth (SDG 8), and reduction of inequality (SDG 10).

This thematic paper is not an exhaustive review of the relationship between health and social protection, but touches on a number of key areas addressed in the high-level conference in Paris. Universal social protection floors for better health and well-being for all children and adolescents page 2

Introduction

Ensuring that all Member States of the WHO European Region have adequate social protection – including universal health coverage and income security for all children and adolescents and their families and communities – is critical to giving all children the best start in life. The installation of social protection floors, which guarantee basic income security and access to essential goods and services for all (including those most at risk of vulnerability), is therefore a critical investment in the health and well-being of young people and future generations (1). Taken together, evidence suggests a bidirectional relationship between social protection and health (2), and good health is a form of social protection. Ill health has been shown to reduce employment prospects – working against SDG 8 – and increase the likelihood of premature retirement and older-age poverty in later years (3). Supporting universal health coverage for all children and adolescents therefore enhances social protection by ensuring access to programmes and services of sufficient quality and protecting children and families against financial hardship over the life-course.

Societies pay a high cost for failing to act early and on time to promote child health and development, particularly for children at risk of vulnerability. It is estimated that children at risk of poor development in low- and middle-income countries are likely to lose out on as much as a quarter of average adult income per year, severely diminishing not only their own social protection, but also potentially that of future generations – the correction of which is critical for the achievement of targets related to SDG 10 (4). Social protection affects health not only by helping to prevent sickness and disability, but also by ensuring financial protection, thereby contributing to universal health coverage and effective access to health care. For example, progress in reducing unmet health need across Europe in the wake of the 2008 economic crisis was not only stalled, but reversed: an additional 1.5 million people had unmet health needs, with deprived groups disproportionately affected (5).

The relationship between social protection and health is critical not only to employment and cycles of production, but also to care work and cycles of reproduction. Ensuring access to sexual and reproductive health services – as called for in SDG 3 – can ensure social protection for all across the life-course. Safe and wanted pregnancies, for instance, are key to ensuring the best start in life for all children by safeguarding the health and well-being of newborns, mothers and, by extension, families and communities. Access to sexual and reproductive health services during the adolescent years is vital to decreasing the risk of sexually transmitted infections and unwanted and unplanned pregnancies (6), and consequently improving employment and career prospects across the life-course .

When carefully designed, and when taken together, social policies such as parental leave, child and family allowances, accessible quality child care services, unemployment benefits, active labour market policies and affordable housing have the potential to strengthen social protection for parents, with indirect benefits for children and adolescents, families and communities. They also promote gender equality, as called for in SDG 5 (3). Universal social protection floors for better health and well-being for all children and adolescents page 3

Providing social protection floors and facilitating intersectoral collaboration

Enhancing social protection is also an investment in the health of broader society. Investing in social protection helps to reduce poverty by stabilizing household income and supporting parents and caregivers, with proven benefits for children and adolescents (2). The social and economic costs of inadequate social protection are extremely high and can take many forms, including: slower rates of economic growth with less resilience, the perpetuation of inequalities across generations, higher unemployment rates, and poorer health (3).

To provide universal social protection floors and facilitate intersectoral collaboration throughout the Region to improve the health and well-being of children and adolescents, it is necessary to do the following. Make universal social protection a priority for a healthy future for all

Social protection has been recognized as a means of improving health since the economic crisis in 2008 (2), addressing the needs of those at most risk of vulnerability and safeguarding development (7). Activities aiming to achieve universal social protection, including rights-based approaches and access to available and affordable services (such as health), assume the availability of sufficient numbers of health workers to deliver services and the minimization of out-of-pocket payments that could hinder access to care. At the same time, creating decent work as a means to achieving universal health coverage contributes significantly to achieving full employment and economic growth (8).

These efforts must be coordinated across relevant sectors and agencies so that all children and adolescents can reach their full potential (4). United Nations agencies, including the International Labour Organization (ILO), International Monetary Fund (IMF), United Nations Development Programme, United Nations Children’s Fund and World Bank, have recognized the importance of social protection. Most recently, the ILO and World Bank announced a partnership to achieve “universal social protection” across the life-course, building on previous efforts that focused on poverty alleviation and comprehensive social protection systems, including national social protection floors comprising essential health care, maternal care and basic income security for children (9). A focus on social protection for all, including children and young people at risk of vulnerability, is critical for reducing inequalities across dimensions such as gender and (dis)ability and among groups of children and young people most at risk of vulnerability, such as unaccompanied migrant children and children at risk of adverse childhood experiences. Collaborate across sectors to deliver on safe pregnancy and neonatal survival

The health sector has a unique ability to affect child health and well-being (even prior to conception) through promoting collaborative partnerships across sectors (10). Guaranteeing access to affordable, high-quality sexual and reproductive health services plays a leading role in ensuring healthy and wanted pregnancies and safe births, but variation in stillbirth rates persists across high-income countries. Substandard care is thought to be responsible for as much as 30% of all stillbirths, leading to almost 20 000 preventable stillbirths in 2015 alone (11). Factors such Universal social protection floors for better health and well-being for all children and adolescents page 4

as diet before and during pregnancy, and smoking during pregnancy and early parenthood, affect health status and outcomes during pregnancy and the earliest stages of child development. Mothers are more likely to breastfeed if they are knowledgeable about the benefits it brings to infant health (12). Health care workers and other family members can promote infant health through improving the health literacy of expectant parents by connecting them to prenatal classes and making them aware of the support available from employers (12,13). Coordinate across sectors to improve antenatal and children’s health services

Member States of the WHO European Region have some of the lowest infant and child mortality rates in the world, but inequalities persist across the Region. Mortality rates for children under 5 years are 25 times higher in countries with the highest mortality rates compared to those with the lowest (14). Inequalities also persist within countries, where children from families at risk of vulnerability struggle to gain access to social services, while simultaneously trying to avoid the stigma attached to using these services. Provision of antenatal and postnatal support varies between countries: the best systems are characterized by universal health coverage, personalized support during and after pregnancy, choice in birth arrangements (including partner involvement), and parenting support and advice to promote comprehensive child health, development and well-being (4,10). Health-promoting nurseries and pre-schools for all children

Access to affordable early childhood education, such as pre-schools and nurseries, and the promotion of nutrition, physical activity and cognitive stimulation in these settings are important elements of social protection for children and families. Affordable nursery and pre-school supports children and families by facilitating parental reintegration into the labour market, with disproportionate effects for women. In the absence of affordable nursery and pre-school, women are less likely to engage in paid work (15), which results in less financial protection for households, the perpetuation of gender-based inequalities, and greater risk of poverty for children (16).

Pre-schools and nurseries can serve as stable platforms from which to provide services that improve health and well-being early in life (17). Evidence suggests that pre-primary education is an effective way of improving educational achievement: children who participate in early childhood education tend to perform better at age 15 than those who do not, after controlling for socioeconomic background (18). These findings highlight the need for safe, accessible pre- school environments for all, regardless of social background.

Inclusive educational environments that promote high-quality health education for health and life skills will improve the health and well-being of future generations, and education starts in pre- school. Schools are a key actor for sustainable development, empowering individuals by addressing the systemic enablers of vulnerability in school settings. Pre-primary education appears to be an effective way of improving educational achievement. Universal social protection floors for better health and well-being for all children and adolescents page 5

Adequate resources and income support for all families and young people

Good health is essential for decent and productive employment, which also contributes to the social protection of workers and their families. The nature of employment influences health outcomes, including those of employees’ children (3). Social protection for children and families across Organisation for Economic Co-operation and Development countries is strongly associated with the employment status of household adults; child poverty rates are almost 15 times as high in households where two or more adults are jobless compared to those where two or more adults are earning (16).

Good health is key to facilitating productive work. Mental illness is the leading cause of disability and missed worked days across the Region (3), but interventions such as active labour market policies (19–22) and lifelong learning programmes have proven helpful in addressing mental health problems, preventing job loss and promoting faster re-employment when necessary – with subsequent benefits for children. In the long run, however, increased labour market participation is only positive for health and well-being if workplaces facilitate health and well-being. The ILO’s Decent work agenda (23) promotes health and well-being for current and future generations by ensuring work and a fair income, safety and health in the workplace, social protection for all, social dialogue, and equality of opportunity and treatment, all of which affect workers and their families (24). Ensure that adequate parental leave is available to all to give children the best start in life

Robust and equitable maternity, paternity and parental leave policies are crucial for giving children the best start in life. Evidence suggests that inadequate maternity, paternity and parental leave can adversely affect child development, hindering speech and cognitive development (25), reducing rates of breastfeeding and immunizations, and increasing child behavioural problems (26). Studies have also shown that increasing the number of weeks of job-protected paid maternity leave significantly reduces low-birth-weight and infant-mortality rates (27).

Adequate levels of maternity, paternity and parental leave have been shown to improve child development, health and well-being (28). Parental leave programmes can enable transformations in gendered stereotypes of care by equalizing the incentives for fathers and mothers to play a role in child care and paid work, respectively (24). These programmes must be carefully designed and tailored to the individual country context to ensure they do more to alleviate, rather than exacerbate, gender inequality. For instance, in many contexts, maternity, paternity and parental leave only applies to workers engaged in formal-sector employment; parents engaged in unpaid work who were not formally employed before having children – most of whom are women – are therefore at risk of being excluded from many social protections. Measures to extend maternity cash benefits to workers in the informal economy through the extension of to previously uncovered workers, tax-financed benefits or a combination of both can help to fill this gap (29).

Universal social protection floors for better health and well-being for all children and adolescents page 6

Ensure proper living conditions – essential for children’s health and well-being

Ensuring universal access to high-quality built environments is crucial to the health, well- being and development of children and adolescents (30). Proper living conditions and affordable and secure housing provision, including social housing, are key to reducing inequalities between generations. Inadequate living and housing conditions pose the highest health risks to groups at risk of vulnerability, particularly children and adolescents (31), negatively affecting their health (32), development (33,34) and educational attainment (35). Affordable and secure housing reduces the effect of economic inequality on low-income families (36), but unaffordable housing can quickly exacerbate the consequences of social disadvantage and is a major risk factor for mental health problems among children and their families (5,37).

Evidence from across the Region finds that those who cannot afford rent or mortgage payments are at greater risk of experiencing depression and suicidal thoughts (38–47). Parents and carers’ mental health issues can also have an impact on children, affecting the quality of care they receive and increasing the risks of anxiety, depression and poor school performance. Poor health can reduce people’s ability to generate income, making it increasingly difficult to meet housing costs; as a result, people with high needs for health protection often find themselves forced into unsuitable or temporary accommodation, which exacerbates their health issues and from which it is hard to exit (48). Take intersectoral action to identify children at higher risk early

Equal and adequate attention must be given to all children and adolescents across all sectors to ensure that no child falls through gaps, and that those at higher risk are identified early. Childhood is a period of extensive brain, physical, emotional and behavioural development that starts in the neonatal period and continues into adolescence. Adverse childhood experiences can result in toxic stress, affecting brain development and causing cognitive impairment and behavioural changes. Adverse childhood experiences include one or more episodes of child maltreatment where there may be emotional, physical and/or sexual abuse, or physical and/or emotional neglect, or due to household dysfunction where a parent or household member has an alcohol or drug problem, mental illness or has been incarcerated, or if there is violent treatment of the mother and/or separation or divorce of parents (49–52).

A lack of safe and nurturing relationships in childhood can also lead to a range of problems that continue into adulthood. It is therefore important to intervene early and take a life-course approach to ensure children’s healthy development. This requires sharing of accountability for the identification of children and adolescents most at risk across sectors, and ensuring that the necessary mix of interventions provided align and complement those from other sectors.

Identifying higher-risk children and adolescents is an intersectoral data issue that requires collaboration and cooperation across sectors at service-provision level to collect data for monitoring and evaluation. Health issues for children tend to coexist with social issues, such as poor levels of educational attainment and school attendance, neglect and even abuse in the family environment. Increased exposure to environmental risks in their daily living environments is common for socially disadvantaged children and must be tackled. The application of adequate and equity-sensitive surveillance systems for health and health determinants would help Universal social protection floors for better health and well-being for all children and adolescents page 7

decision-makers to identify high-risk children earlier and select an appropriate mix of interventions, reducing the likelihood of poverty and vulnerability being perpetuated through generations. Ensure intersectoral information-sharing, referral procedures and follow-up

Addressing vulnerabilities in children as early as possible once identified requires cooperation and collaboration among settings in the health, education and social sectors (school, health, child protection and social services). Intersectoral information-sharing and joined-up intersectoral action is crucial to ensure that children and adolescents do not fall through the gaps between services and that no child is left behind. Fatal child abuse cases regularly identify communication problems between professionals (53), so creating the cultural context and governance architecture to facilitate intersectoral communication and data-sharing is important in allowing workers in different sectors to collaborate. The sharing of data at operational, service-provision level, coupled with effective and efficient referral and follow-up processes, is necessary for services and systems effectively to ensure universal protection of children, adolescents and their families.

Referral and follow-up procedures must extend beyond the child, however, and be individualized, family-friendly and family-centred. Evidence shows that place of residence (8) and family poverty are key determinants of re-referral for children to social services (54): follow-up should therefore not overlook the wider family and social environment of the child and ensure services and interventions that are appropriate to the whole family are provided.

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