Report | Doc. 14194 | 24 October 2016

Ensuring access to health care for all children in Europe

Committee on Social Affairs, Health and Sustainable Development

Rapporteur : Ms Stella KYRIAKIDES, Cyprus, EPP/CD

Origin - Reference to committee: Doc. 13402, Reference 4027 of 7 March 2014. 2016 - November Standing Committee

Summary

Even today, not all children in Europe enjoy equal access to health care services. Since the most recent economic crisis, access to health care has notably become more difficult for children and families living in precarious situations, for example due to unemployment, poverty or migration. Health systems across Europe are affected in different ways, but many of them need rebuilding or consolidating with a view to guaranteeing “the highest attainable standard of health” to all children, as provided by the United Nations Convention on the Rights of the Child.

The Parliamentary Assembly should express its concern about the persistent inequalities observed across Europe with regard to the availability and accessibility of health services for children and their subsequent health results. Next to adequate funding for public health systems and improved data collection in this field, member States should address the social determinants of health (including inequalities in education and income), develop health literacy programmes, provide special support to the most vulnerable groups of children and promote new approaches to child participation.

A. Draft resolution

(open)

1. European health care systems show significant gaps in the provision of health care to children, even though they remain among the most accessible globally. Under the impact of the most recent economic crisis and related austerity programmes, access to health care has notably become more difficult for children already living in precarious conditions or belonging to vulnerable groups, but all countries – poorer and richer ones alike – face their own specific challenges with regard to health care provided to children.

2. The Parliamentary Assembly is concerned about the inequalities across Europe and within European countries concerning the right of children to the “highest attainable standard of health”, both in terms of availability and accessibility of health care services and health results. Quality health care services for children should not only be made available, but should also be effectively accessible to all children in a country, whatever their socio-economic, ethnic or migrant background, geographical location, state of health or legal status in a given country.

3. The Assembly calls on member States to comply with the relevant international and European standards, including the United Nations Convention on the Rights of the Child, the European Social Charter (ETS No. 163) and the Convention on Human Rights and Biomedicine (ETS No. 164). Governments should promote child-friendly health care systems according to the relevant Council of Europe guidelines, and make them a priority of public health policies. The importance of and way forward with regard to the health of children and adolescents is also outlined by the World Health Organization (WHO) in its new “European child and adolescent health strategy 2015-2020” – an essential reference in this field.

4. Whilst the most urgent task will be that of rebuilding adequate services in countries where health systems have suffered from the economic crisis and austerity programmes, a further challenge consists in ensuring healthy living conditions and providing health care services to children and families living in precarious situations, due to unemployment, poverty, war or migration, for example. Child-friendly health care systems also require appropriate prevention programmes according to Assembly Recommendation 1959 (2011) on preventive health care policies in the Council of Europe member States.

5. Against this background, the Assembly calls on the member States of the Council of Europe to:

5.1. ensure adequate funding to develop health care systems of the highest standard possible to be provided to all children in an equitable manner across every country, which are comprehensive (thus including prevention, diagnosis, treatment, rehabilitation and palliative care), address health emergencies and chronic diseases in terms of physical and mental health, ensure the provision of medicines to all children, and put an emphasis on prevention from an early age, including antenatal health care;

5.2. improve data collection in the health field with a view to measuring current gaps in children’s access to health care and assessing the effectiveness of health policies, disaggregated by age group (smaller children and adolescents) and covering both physical and mental health issues;

5.3. address the fundamental social determinants of health, such as poverty, income inequalities and education levels, but also environmental determinants, with a view to improving health and access to health care services;

5.4. develop health literacy through specific programmes, dispensed via educational systems or targeted at specific categories of the population, including disseminating basic knowledge of symptoms requiring medical attention and healthy ways of living, as well as information about the functioning of health systems;

5.5. promote a new approach to informing children about and consulting them on health decisions concerning them, and let children participate in the planning, design and delivery of health care where appropriate, thus implementing the highest standards of child participation;

5.6. provide special support to the most vulnerable groups of children, including by putting in place targeted programmes to respond to their specific needs, as well as by:

5.6.1. setting up regular screening programmes for all children via schools, including children living in poverty or in families with low levels of health literacy, in line with WHO standards in this field;

5.6.2. developing programmes to improve the presence of and access to health workers in remote rural areas through training, regulation and (where appropriate) financial incentives, as well as to support children and families in reaching the nearest health care centres;

5.6.3. improving access for children with disabilities to quality, affordable health care services by reviewing legislation and policies, increasing targeted budgets and improving service delivery;

5.6.4. in the light of the current refugee crisis, taking immediate action to guarantee access for children “on the move” (migrants and refugees) to quality health care, independently of their legal status and without discrimination based on gender, age, religion, nationality or race;

5.6.5. in the same context, dedicating special attention and resources to children affected by armed conflicts, either by physical injuries requiring aftercare or by traumatising incidents having led to a significant increase in mental health problems among children;

5.6.6. taking action to guarantee access to quality health care for children of ethnic minorities, such as Roma and Traveller children, including through specific outreach programmes designed to overcome reluctance to turn to public health services;

5.6.7. providing specific training programmes for health care professionals to help them address culturally sensitive matters, such as sexual and reproductive health, and deal with traumatised children;

5.7. co-operate to provide support in delivering access to health care for all children to countries with the most need and the least resources.

6. Improved accessibility to health care systems should also include complaint mechanisms for patients encountering dysfunctions of the system and unequal treatment, inspection bodies in charge of supervising health facilities and quality management systems to improve services wherever needed.

B. Explanatory memorandum by Ms Stella Kyriakides, rapporteur

(open)

1. Introduction

1. Children have manifold needs to be fulfilled so that they can experience a safe and happy childhood and become adults capable of living autonomous and happy lives. From birth onwards, they all need food, shelter, safety and protection. Next to basic physical care, they also require affection, emotional security, stimulation, guidance and control. In line with their respective age, they must also be given responsibility and acquire increasing independence.

According to the United Nations Convention on the Rights of the Child (UNCRC), children must be guaranteed the full set of human rights. In the spirit of the indivisibility of fundamental rights, these also include social rights such as the right to the highest attainable standard of health, social security, adequate standards of living, education, as well as rest and leisure.

2. Despite widespread awareness of children’s needs of protection and care, many children in Europe still do not see their basic needs met – for various reasons. The financial and economic crisis has hit numerous countries, and austerity measures have exacerbated inequalities, caused by socio-economic developments, demographic trends and increased migration flows. In this context, many families, even in Europe, have difficulty in obtaining a regular and adequate income, in providing full parental protection and care for their children or in accessing various public services.

3. Amongst the essential needs of children that remain unsatisfied in the current socio-economic context is effective and full access to health care services. Cuts applied to public budgets under austerity programmes regularly ignore the specific needs of children and the short- and long-term consequences that limited support to them may cause for their personal well-being, development and equal opportunities, as well as, in the long-term, for society as a whole. The present report wishes to explore some of the main challenges with regard to the full provision of health care services to children and point to the areas where action is needed most urgently.

4. Specific questions with regard to children are: In which ways are they hindered or discriminated against in their access to health care? Which are the main categories of children in need of special support in accessing health care services? Such questions have, amongst others, been explored via a fact-finding visit to Greece in October 2014, an exchange of views with international experts at the meeting of the Committee on Social Affairs, Health and Sustainable Development held in Chișinău (Republic of Moldova) in May 2015, and addressed by a dedicated written contribution from the organisation Médecins du Monde. I would have liked to spend more time examining the situation prevailing in different countries, given that all countries of Europe are facing the challenge in one way or another, but such comprehensive research would clearly have exceeded the scope of this report.

2. Standards of health care: which measures to apply in evaluating children’s health care?

5. Identifying gaps in legislative and political action involves the confrontation of real-life situations with European standards. The Council of Europe itself, although unfortunately having ended its specific intergovernmental activities in the health field a few years ago, has developed a number of instruments in this area. The Parliamentary Assembly continues to monitor developments in the public health sector through our committee, and has pointed to a number of issues in the past years.

2.1. International standards in the health field

6. Children’s right to the “highest attainable standard of health” is first guaranteed by Article 24 of the UNCRC, whilst, at Council of Europe level, the “right to protection of health” more generally is also enshrined in the European Social Charter (ETS No. 163) and the Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164, “Oviedo Convention”) requiring that member States ensure “equitable access to health care of appropriate quality” within their jurisdictions.

7. In 2011, the Committee of Ministers of the Council of Europe also adopted a more specific, but non-binding, standard on child-friendly health care: the “Guidelines on child-friendly health care”. These guidelines call for health care services to take into account children’s rights, needs, characteristics, assets, evolving capacities and own opinions.

At European Union level, Article 35 of the Charter of Fundamental Rights states that “everyone has the right to access preventive health care and the right to benefit from medical treatment under the conditions established by national laws and practices”.

8. As parliamentarians, it is our responsibility to contribute to the effective implementation of these standards. The Parliamentary Assembly for its part has already pointed to the lack of comprehensive health prevention policies in many countries through its work leading up to Recommendation 1959 (2011) on preventive health care policies in the Council of Europe member States, in which it called on governments to “support a good start in life for families and young children by strengthening preventive health care before pregnancy and for mothers and babies in pre- and post-natal, paediatric and school clinics, and through improvements in the educational levels of parents and children”. Effective health policies should always contain a strong component of early prevention given that many health problems occurring in adult life may be prevented through appropriate screening or treatment in childhood.

9. Guidance for improving health services for children and adolescents may also be found in the new “European child and adolescent health strategy 2015-2020” of the World Health Organization (WHO) aimed at “[enabling] children to realize their full potential for health, development and well-being” and “reduce their burden of avoidable disease and mortality”. Among health priorities under this current programme, WHO quotes the remaining challenges linked to preventable death and infectious disease, early childhood and adolescent development, reducing exposure to violence, promoting healthy ways of living through nutrition and abstention from tobacco and alcohol consumption, tackling mental health problems and protecting children and adolescents from environmental risks. More specific recommendations are made by WHO in its 2014 “European framework for quality standards in school health services and competences for school health professionals”.

2.2. Access to health care – defining the concept

10. The Sustainable Development Goals adopted by the United Nations in 2015 intend to achieve “universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” under Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”). To achieve universal health coverage, health policies and health systems should be based on the principles of: i) availability; ii) accessibility; iii) acceptability; iv) contact; and v) effective coverage.

11. WHO defines accessibility as “a measure of the proportion of the population that reaches appropriate health services”, understanding availability as including physical access, travel facilities and affordability (user fees, health expenditure and transport).

Universal health coverage means achieving good health services de facto, so coverage and access are complementary ideas.

Even if services exist and people have access to them, they might not always use them; access also involves the opportunity or ability to receive health services and, as such, can be measured by utilisation rates. Another accessibility measure is the outcome of services in terms of health results. Measuring equity of access to health services is a core component of performance assessments for health systems.

12. A major issue concerning access to health care services lies in the situation of vulnerable groups, such as persons with disabilities or migrants, who may meet financial, organisational, social or cultural barriers in accessing health care services.

National health policies should therefore also include measures aimed at lifting such barriers. Continuity of access is crucial and must be based on need rather than ability and/or willingness to pay.

2.3. Child participation in health care provision – luxury concept or state of mind?

13. Next to accessibility questions, “child-friendliness” in public service provision has received increasing attention over the past decade. The concept includes the participation of children in all decisions concerning them, inspired by Article 12 of the UNCRC which states that “a child who is capable of forming her or his own views [should have] the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child”.

14. The above-mentioned Council of Europe guidelines on child-friendly health care also contain a chapter on child participation, specifying for the health field that: a child should give his or her free consent, or if not yet able to do so, see his or her opinion taken into account in proportion to his or her age and degree of maturity; all children should be given appropriate information before medical interventions; children should be given the opportunity to take part in social decision-making processes, including the assessment, planning and improvement of health care services.

15. Although, in different contexts, child participation may be based on very sophisticated (and sometimes costly) procedures of consultation or collaboration, it is first based on a new state of mind. It includes recognition of the fact that every child is a bearer of the full set of human rights. So even in countries where public authorities do not have the funding to develop specific child-participation mechanisms, their participation in decisions concerning them should be allowed and promoted. The area of health care where children’s health, identity and well-being is concerned is crucial in this respect.

3. The issue at stake – children’s access to child-friendly health care services

16. To fully grasp the issue at stake, it is important to look into general determinants of the access to health care in Europe, but also into challenges specific to children and the most vulnerable groups amongst them. An important distinction to be made in practice is the one between children and adolescents. Whilst both are defined as children (in the sense of minors under 18), according to the UNCRC definition, smaller children and adolescents are not concerned by the same health issues but have special needs according to their age group and specific risks linked to it.

3.1. General determinants of health and access to health care for children in Europe

17. Access to health care services means that people have the power to demand appropriate health resources in order to protect or improve their health. Whilst some may have unhindered access to health services, others may encounter obstacles in gaining access. Amongst the legal, financial, cultural or geographical barriers for certain groups are:

a lack of insurance coverage (especially affecting migrants, ethnic minorities, the long-term unemployed or the homeless);

the inability to pay the direct costs of care (for example for low-income groups);

a lack of mobility (for example for disabled persons);

a lack of language competence (for migrants and ethnic minorities);

a lack of access to information (for the poorly educated, migrants or ethnic minorities);

time constraints (for example for single mothers);

specific financial barriers for low-income groups and patients with chronic diseases;

health literacy and health beliefs (including certain traditions and cultural practices) of specific social groups, also hindering access to facilities and information on sexual and reproductive health;

uneven geographical coverage and lack of health care services and workers in remote rural areas.

18. Among the categories of the population regularly seen as disadvantaged in the health field in Europe are the Roma and Traveller population, people with physical disabilities or mental disorders, people suffering from chronic diseases, the unemployed, people with poor living or working conditions, migrants and refugees, the elderly and women.

Children, who are generally dependant on their parents’ (or other adults’) support in accessing health care services, face specific obstacles. These can be linked to their families’ socio-economic situation, educational level or level of “health literacy”, including a basic understanding of the human body, of the symptoms and causes of diseases and of the functioning of the national health system.

19. In this respect, we also need to distinguish between access to health and health care services. The living conditions encountered by many children may already represent serious health risks, for example due to bad housing conditions, undernourishment, unhealthy lifestyles or domestic violence. Access to health care services then becomes another issue in which children regularly encounter the same difficulties as adults.

3.2. Children and health – topical challenges observed across Europe

20. A paper specially prepared by Médecins du Monde in 2015 for the purpose of the present report provides the following observations:

socio-economic barriers in accessing health care are similar in different European countries. They often involve loopholes in legal provisions, financial hardship and difficult living conditions, administrative barriers, a lack of understanding about health care systems and language barriers;

such barriers exist from an early stage of a child’s life (2013: close to 70% of pregnant women without access to antenatal care before coming to a Médecins du Monde health centre; nearly 50% of minors lacked essential vaccines (such as mumps, measles and rubella, pertussis or tetanus)), in some cases, birth certificates had been refused to children whose mothers were unable to pay for services;

access to health care for children is determined by their parents’ ability to access health services;

children (and their fundamental rights) have been the first victims of the economic crisis and subsequent austerity measures (including through increasing xenophobia);

particular vulnerability is observed amongst undocumented and unaccompanied minor migrants, children of seriously ill migrants and Roma and Traveller children.

21. Some of the specific problems of migrants as identified by Médecins du Monde notably concern children: overcrowded accommodation and living conditions affecting children’s development, poorly equipped housing (water, heating, sanitation), unhealthy surroundings, residential instability causing stress, and stress and fears linked to the family’s unstable situation, as well as xenophobia, racism and discrimination. Médecins du Monde as an organisation becomes part of the solution offered to children given that they regularly provide emergency health care to those most in need, including migrant and refugee children.

22. In their 2012 reply to the Office of the High Commissioner for Human Rights (OHCHR), the Office of the Children’s Commissioner for England identified the following main challenges in terms of children and health care, which can also be considered as typical to a certain extent:

the impact of poverty on children’s and young people’s health (for example specific pathologies linked to poor nutrition and lack of physical exercise);

lack of direct involvement of children in planning, designing and delivering health and social care;

unmet health needs of young people within the youth justice setting and care system (increased mental health problems amongst children in institutional care);

the effects of parental alcohol misuse on the lives of children and young people;

health needs of unaccompanied and separated children (increased prevalence of post-traumatic stress disorders (PTSD));

health needs and data sharing related to child sexual exploitation (more data are needed to effectively fight abuse and its health consequences).

23. Reports on current determinants of children’s access to health care have been received from various international experts,

who conveyed the following key messages to our committee:

Child protection mechanisms still need to be improved significantly in eastern European countries, where access to health services remains a long-term challenge, and includes the need to address specific issues like child or maternal mortality, or access to care in rural areas;

Action is also needed in western Europe: data from Spain, for example, shows that access to health care is an issue for the 26.3% of the population living under the poverty line and the 34.9% of the population at risk of poverty or social exclusion. Health results are worse among children living in vulnerable families. Growing poverty has also contributed to an increase in domestic violence. The middle class is increasingly affected by the crisis, sometimes leading to the loss of homes;

According to Médecins du Monde data, 62.9% of the people seen by the organisation in Europe had no health care coverage, the main barrier being restrictive legislation excluding certain groups. The fear of being expelled prevents many migrants from attending health services, notably in countries where professionals are obliged to report undocumented migrants;

Médecins du Monde subsequently called on all European countries to: 1) disconnect migration and health policies; 2) improve vaccination across Europe; 3) ensure solidarity, equality and equity in public health systems for everyone living in Europe; 4) ensure access to vaccination and paediatric care for all children (including prenatal care).

24. For this report, special attention was paid to the situation in Greece where I had the opportunity to undertake a fact-finding visit in October 2014, at a time when the country was particularly suffering from the effects of austerity programmes and budgetary cuts in the health system.

During my visit to Athens, I learned that accessibility for children to health care was limited, in particular in rural and insular areas due to the lack of paediatricians and financial difficulties, whilst all children had access to vaccination and received support for accessing other health services if needed (for example unaccompanied children). Already according to earlier reports, austerity measures imposed on Greece in 2010, including cuts to health services, have affected people through increased rates of child poverty and malnutrition, HIV infections, suicides (and attempts) and stillbirths. Other dramatic effects are still expected in cancer screening and management.

25. In 2012, the United Nations stated that “the right to health and access to health services [was] not respected for all children in Greece”. Reduced access to prenatal health services for women had led to an increase in neonatal and post-neonatal deaths.

In 2013, UNICEF drew attention to the number of children whose parents had lost their social insurance coverage.

This was confirmed by the 2015 WHO report on “Barriers and Facilitating Factors in Access to Health Services in Greece”, which noted that the economic crisis had resulted in more than 2.5 million people losing their social insurance rights.

26. Médecins du Monde, currently running 16 programmes for different target groups in Greece, noted that, amongst other social problems (for example more than 40% of children living in poverty, rising intolerance and xenophobia), a topical challenge was the 30% of the population without health coverage. Amongst migrants, only formal asylum seekers, undocumented migrants under 14 years of age and women giving birth, were provided with public health services (except for prenatal care), and significant problems existed in cases of chronic or serious illness. The country did not have sufficient means to respond to the needs of all people arriving in Greece, many of whom had suffered torture or undertaken life-threatening sea journeys.

27. Whilst Greece was severely hit by the crisis and has been in the first line of countries receiving migrants and refugees in recent years, problems may also be observed in wealthier countries, such as Switzerland. Over the past decade, the Swiss health sector has suffered from an insufficient number of paediatricians and seen an increasing centralisation of paediatric care. Consequently, the United Nations Committee for the Rights of the Child recommended that the Swiss Government take action to ensure a high level of paediatric care. However, it has to be noted that efforts have been made to increase equality in the health sector. Most recently, insurance premiums for children for low- and middle-income families have seen a reduction of at least 50%.

28. With regard to child and adolescent health generally, special attention also needs to be paid to mental health issues. Relevant measures should both be part of preventive health strategies (for mental problems that may be treated before reaching adult age), others will accompany persons concerned all their lives. According to WHO, 10%-20% of children and adolescents experience mental disorders worldwide, and half of all mental illnesses begin by the age of 14 (and three quarters by the mid-20s).

If untreated, certain neuropsychiatric conditions may lead to disabilities and influence children’s development, their educational attainments and their potential to live fulfilling lives. Addressing children’s and adolescents’ mental health problems is a complex matter and requires specific strategies following differentiated approaches. Such strategies must tackle depression, eating disorders and other, sometimes hereditary, mental health problems, but also relate to substance abuse or the psychological effects of violence experienced or witnessed by children.

29. Coming back to more general observations valid for many countries, an integral part of prevention strategies, including in terms of mental health, should be efforts to avoid “unhealthy” life situations for children, including for those living in large childcare institutions. A recent study carried out among Romanian children (aged 12) showed that early institutional care may have detrimental effects and lead to physical and mental development setbacks which would then require significant medical interventions at a later stage in their lives. The study further revealed that an optimal solution for children without parental care would be stable long-term foster care placements.

As said previously, unhealthy life situations may also find their origin in other social determinants, such as poor living conditions caused by unemployment, absence or sickness of one or both parents. Finally, we must not forget about the increasingly frequent environmental causes, such as living near nuclear power stations, waste incineration plants or other polluting infrastructure facilities, or limited access to safe drinking water or good sanitary facilities.

30. Finally, an aspect not to be neglected is that of children’s access to medicines.

For many years, the European Union has tried to promote the development of child-specific medicines by the pharmaceutical industry.

However, testing medicines on children is not always easy (for example due to the lack of parental consent) or cost-effective, and the market share of child medicines is estimated at only 3% of the “adult” market, which does not justify major investment for pharmaceutical companies.

3.3. Vulnerable categories of children

3.3.1. Poor children

31. Evidence gathered by European experts shows that in particular children coming from disadvantaged social backgrounds suffer from inequalities in accessing health care. There is certainly room for improvement in terms of accessibility and responsiveness to the needs of poorer children: in some countries, children are covered by insurance only if their parents are, hence if their carers cannot afford insurance, children are not insured.

The economic crisis and austerity measures targeting social programmes such as health care and welfare support have affected poor and disadvantaged children to a greater extent, undermining their right to the highest standards of health.

32. In some countries, problems are found to be cutting across different categories of children. For the Republic of Moldova, for example, WHO findings suggest that both poor people and people in rural areas belong to the most excluded, preferring to avoid contact with health services until it becomes impossible to delay.

Amongst the most marginalised groups in the country is the Roma and Traveller population, with a significant share of children having no health insurance.

33. The Republic of Moldova, one of Europe’s poorest countries, is just one example where we can see how inequalities in the health sector were exacerbated and how health services deteriorated following the financial crisis, but this certainly occurred in a similar manner in various other countries. The Republic of Moldova’s current share of health expenditure (5.3% of gross domestic product (GDP) in 2014) is actually smaller than in other countries of the region, whereas the share of private health expenditure (5% in 2014) is relatively high.

As a result, the poorest are facing excessive health costs, and, due to a lack of consistent planning, family medicine is marked by significant deficits, particularly in rural areas.

Income disparities significantly affect children’s health: stunting (malnutrition leading to growth failure) strikes nearly four times more children from poor families.

High levels of substance abuse and alcohol consumption among adolescents and low knowledge about HIV/AIDs prevention put young people at risk.

3.3.2. Children in remote rural areas

34. Significant discrepancies also exist between the rural and urban populations in terms of access to high quality essential services such as health services. Evidence indicates disparities in the presence and number of qualified health care personnel, proximity to large hospitals, effectiveness of emergency care services, quality of the infrastructure and demands on health workers. Other inequalities include access to specialised services, health promotion and prevention activities, as well as financial barriers.

The latest “Health at a Glance: Europe 2014” report by the Organisation for Economic Co-operation and Development (OECD) confirms that in all member countries, the density of doctors is much greater in urban regions.

35. In this context, the United Kingdom, for example, has introduced a promising policy practice to ensure better access to health services in remote areas: “Rural proofing – policy maker’s checklist”

to ensure that the needs of rural populations are taken into account during the development and implementation of policies and programmes. In 2013, the Department for Environment, Food And Rural Affairs (DEFRA) published National Proofing Guidelines which provide support and advice to government officials.

However, the scope of this report did not allow the implementation of these policies and their actual impact to be explored in more detail.

3.3.3. Children with disabilities

36. Another vulnerable category are children with special needs due to physical or mental disabilities. According to WHO, people with disabilities report seeking more health care and having greater unmet needs. Health prevention activities seldom target people with disabilities.

For children and adolescents with disabilities, even easily curable illnesses like fever or diarrhoea can become life-threatening if left untreated; some children may not survive childhood because of a lack of primary health care facilities; rehabilitation services are often concentrated in urban areas and are expensive, thus non-accessible for many; children with disabilities will often have to be left in institutions by their parents while receiving care – with profound psychological consequences.

37. Countries should develop specific programmes guaranteeing better service access and inclusion for children with disabilities and find solutions to reduce “out-of-pocket” expenditure for families. Children should be empowered through information and peer support, while professionals should receive specific training and tools, including to overcome communication difficulties encountered by some children.

3.3.4. Children “on the move”

38. Because of their exposure to migratory stress, children “on the move” (including migrants and refugees) are particularly vulnerable, not least because their health can quickly deteriorate when they do not have access to adequate care.

As reported by Médecins du Monde, the two main barriers encountered are administrative problems (lack of legal access to health care) and a lack of understanding or knowledge of rights. Additional elements that may discourage children from seeking health care include language barriers or fear of being arrested.

39. Grave concerns are also being raised about the impact of living conditions in refugee camps on children’s health, whilst health care services in camps being very limited.

Health care services for migrants and refugees must be adapted so as to avoid increasing anxiety in both individuals and the wider community, including through training of health care professionals to address culturally sensitive issues and to overcome communication difficulties. States must be made aware that it is not only in the interest of the individual to receive health care and proper treatment, but also in their own interest to deliver it, for example to avoid the spreading of infectious diseases.

40. Good practice is noted in the United Kingdom where, in the framework of its National Health Service (NHS), asylum seekers, refugees and trafficking survivors are amongst the groups that are exempt from all charges relating to health care. The NHS aims to ensure free access to primary care, walk-in centres, accident and emergency units as well as diagnosis and treatment of infectious diseases. Any urgent or immediately required treatment, including antenatal care, must be delivered; however it may be charged afterwards.

41. Despite the easing of access for asylum seekers, refugees and trafficking survivors, migrants are a particularly vulnerable category of the population in the United Kingdom in terms of access to health services. More specifically, the government has been more indisposed towards irregular immigrants with regard to health care access, as proven for instance by the introduction of the Migrant and Visitor NHS Cost Recovery Programme, which led to hospitals routinely asking about someone’s immigration status before they access health care. Médecins du Monde labelled children of undocumented migrants as one of the most vulnerable groups in the United Kingdom, with 50% of the children attending the organisation’s family clinic having had no access to health care, including essential vaccinations.

3.3.5. Children from ethnic minorities

42. Children from ethnic and linguistic minorities, in addition to being victims of structural discrimination, are often raised in poor socio-economic conditions, thus undermining their access to adequate health services. Roma and Traveller children are amongst the most vulnerable groups identified. Evictions and deportations result in the discontinuation of care, poor compliance with medication and ineffective monitoring and follow-up. Other barriers that Roma and Traveller populations face, but which are also observed among other minority groups, include language difficulties, lack of health literacy, discrimination, lack of insurance as well as physical barriers such as mobility and distance.

Finally, data available on minority communities, and more particularly on children, is fragmented, therefore hindering the development of effective social inclusion policies.

3.3.6. Antenatal health care

43. As already underlined by the Assembly in Resolution 1959 (2011) on preventive health care policies in the Council of Europe member States, antenatal health care is a precondition for children’s health. Although European countries aim for universal health coverage, inequalities in access to maternal health care persist. Challenges include gaps in statutory coverage, specific eligibility criteria or limited scope of benefit. For instance, social and maternity protection often requires formal employment, full-time contracts or permanent residency. Hence, women employed part-time or facing difficulties accessing the labour market do not always qualify for protection. This means that the most vulnerable groups are often excluded from social health insurance, putting them at higher risk of out-of-pocket expenditure.

4. Conclusions and recommendations: action required urgently and in the long term

44. After having looked at topical challenges, European standards and expert recommendations, I wish to point to a number of legislative, political and administrative measures which would be needed to improve access to health care services for all children both to address the most urgent problems and to induce structural changes in a sustainable manner, with a view to forwarding them to the authorities of Council of Europe member States.

45. Whilst Europe, in comparison with other regions of the world, certainly has more or less solid health care systems in which much attention is paid to children’s specific needs, there are still significant gaps in certain areas and inequalities both across and within European countries. For the sake of our children, we should do our utmost to fill these gaps because their well-being now and in the future is of the greatest importance for our societies as a whole. Health care services for children should therefore not only be made available, but should also be accessible to all children in a given country, whatever their socio-economic, ethnic or migrant background, geographical location, state of health or legal status. Services for children should also be based on the highest standards of “child-friendliness” and involve informing them, consulting them and letting them participate to the greatest extent possible.

46. The most urgent situations to be tackled are probably those in countries where welfare and public health systems have suffered from the economic crisis and related austerity programmes and need rebuilding. A big challenge is also represented by the significant migration and refugee flows, in the context of which public authorities are not only asked to provide healthy living conditions for children and families, but also to ensure both basic and specific health care services for them. In the long term, investing in child-accessible and child-friendly health care systems needs to focus on prevention programmes not only involving families directly, but also through childcare and educational institutions.

47. Against this background, member States of the Council of Europe should be invited to apply the measures presented in the draft resolution.