CDDECS-ENF(2014)3

 

9 October 2014

 

 

 

 

 

 

 

Committee of Experts on the Council of Europe strategy

for the rights of the child (2016-2019)

(DECS-ENF)

 

 

 

Document prepared by the Secretariat for the attention of the European Committee for Social Cohesion, Human Dignity and Equality (CDDECS)

 

 

 

 

 

 

 

Survey on Child Friendly Healthcare

 

 

 

 

 

 

 

 

 

 

 

 

This document is public. It will not be distributed at the meeting. Please bring this copy.

 

Part 1: Background

 

1. Information on the Guidelines and Lisbon Declaration on Child-Friendly Healthcare

 

The Guidelines on Child-Friendly Healthcare (hereafter the Guidelines) were adopted by the Committee of Ministers of the Council of Europe (CoE) on 21 September 2011. The Guidelines are informed by various universal and European standards protecting children’s rights, including the Convention on the Rights of the Child (CRC) and refer to the work of the CoE Programme “Building a Europe for and with Children”, its 2009-2011 Strategy and the ongoing 2012-2015 Strategy on the Rights of the Child.

 

The Guidelines define “Child-Friendly Healthcare” as “health care policy and practice that are centred on children’s rights, needs, characteristics, assets and evolving capacities, taking into account their own opinion.”

 

The aim of the Child-Friendly Healthcare approach is to integrate the relevant rights of children with respect to health and healthcare into a practical framework that drives cultural change and consequent improvement in all services which contribute to the health and well-being of children. This approach should be applicable at the level of policy/planning development, at the service-delivery level and at the level of individual children and families. The approach is universal, but one which each member state can adapt to its own situation.

 

The Child-Friendly Healthcare approach is based on children’s fundamental rights as enshrined in international standards, namely dignity, equitable access to quality health care, the best interests of the child and the active participation of children and their families or carers in the planning, delivery and improvement of all services. Furthermore, the implementation of a Child-Friendly Healthcare approach must include the following principles and actions:

 

• The right of children to participate in their care, including the right to be informed, consulted and heard, to give their opinions independently from their parents and to have their opinions taken into account;
• The promotion of children’s health, which entails the enabling process of children to increase control over their own health and their exposure to positive determinants of health;
• The protection of children’s health to avoid exposure to hazards that may cause harm to children;
• The prevention of illness, which includes reduction of adverse health determinants, as well as, the prevention of further complications of an illness or condition; and
• The provision of child-friendly services and facilities.

 

The Lisbon Declaration on Child-Friendly Healthcare (2011) supports the Guidelines and calls for the need for appropriately skilled healthcare professionals and adequate facilities and services, which take due account of the best interests, needs and well-being of children. It further provides examples on how to apply the Child-Friendly Healthcare approach in hospitals and health services.

 

2. Purpose of the Survey and the envisaged CoE project on Child-Friendly Healthcare

 

The overall purpose of the Survey is to monitor member state progress concerning the implementation of the Guidelines. In line with the CoE Strategy for the rights of the child 2012-2015, the Survey will enable the CoE to gather information on the adoption and implementation of laws and policies regarding Child-Friendly Healthcare. In turn, this will strengthen CoE capacity to ensure the implementation of standards and in the provision of comprehensive and reliable data on the implementation of children’s rights in health. The Survey will also contribute to filling a gap in Europe concerning available data on children’s rights in health at legislation, policy and health service delivery level.

 

Taking into account that the overarching goal for 2012-15 of the Programme “Building a Europe for and with children” will be to achieve effective implementation of existing children’s rights standards, the role of the CoE in monitoring human rights and the Child-Friendly Healthcare approach, as set forth in the Guidelines, the Survey has been divided into five sections, as follows:

 

1. Legislation aimed at implementing Child-Friendly Healthcare;
2. Current policies and programmes at national level;
3. Health service delivery;
4. Capacity building measures for professionals;
5. National practices which have proven to be effective.

 

3. Explanatory notes to facilitate member states’ replies to the Questionnaire

 

Part 3 of this survey aims at helping the ministerial officer(s) filling in the survey. The section includes explanatory notes describing briefly what the question means and/or why it is relevant, definitions of key concepts and reference to specific paragraphs of the Guidelines and/or the Lisbon Declaration on Child-Friendly Healthcare.

 

 

Part 2: Survey

 

Legislation aimed at implementing Child-Friendly Healthcare
		Question		Yes				No
1.1		Has there been any review of domestic legislation to ensure the implementation of the Guidelines?
		If yes, please specify
1.2		Has your government adopted relevant Council of Europe instruments concerning children’s rights?
		If yes, please specify
1.3		Is there legislation in place to ensure equitable access to quality health care services for all children?
		If yes, please provide examples
1.4		Is there legislation in place to ensure the protection of vulnerable children?
		If yes, please provide examples
1.5		Is there legislation on informed consent to medical treatment for children?
		If yes, please specify what criteria is used
1.6		Are there other legal provisions to ensure the fulfilment of children’s rights to information and participation in healthcare?
		If yes, please provide examples
1.7		Are there evidenced-based national guidelines and protocols to guide healthcare delivery?
		If yes, please provide examples
1.8		Are there goals, regular reports, indicators or other mechanisms in place to monitor progress of the implementation of legislation related to Child-Friendly Healthcare?
		If yes, please provide examples
1.9		Where necessary, are budgets allocated for the implementation of legislation related to Child-Friendly Healthcare?
		If yes, please provide examples
Current policies and programmes at national level
	Question					Yes				No
2.1	Has the content of the Guidelines been disseminated nationally?
2.1.1.	If yes, has it been disseminated in child-friendly languages and formats?
2.1.2.	If yes, has it been disseminated among authorities responsible for or otherwise involved with children’s rights in healthcare services, service providers, and groups representing the interests of children and families or other stakeholders?
	If yes, please give examples
2.2	Have the Guidelines on Child-Friendly Healthcare been included fully or partially in any national strategy, action plan or other policy document?
2.2.1.	If yes, does it include children’s health promotion?
2.2.2.	If yes, does it include child protection?
2.2.3	If yes, does it include children’s illness prevention?
2.2.4	If yes, does it include the provision of Child-Friendly Healthcare services and facilities?
2.2.5	If yes, does it take into account children’s social determinants of health?
2.2.6	If yes, was it planned in consultation with children?
	If yes, please explain how children participated
2.3	Are there policies in place to ensure the coordination and referral between different levels of government and different levels of health-service provision?
	If yes, please provide examples
2.4	Are there cross-sector policies in place (including education, social care, justice, environment or other sectors) regarding different aspects of Child-Friendly Healthcare?
	If yes, please provide examples
2.5	Are there protocols in place with the private or voluntary sector regarding different aspects of Child-Friendly Healthcare?
	If yes, please provide examples
2.6	Do the government/health services engage in the exchange of good practices and international cooperation in the field of Child-Friendly Healthcare?
2.7	Are there goals, regular reports, indicators or other mechanisms in place to monitor progress of the implementation of national policies, action plans and/or strategies?
	If yes, please provide examples
2.8	Where necessary, are budgets allocated for the implementation of policies related to Child-Friendly Healthcare?
Health service delivery
	Question		Yes				No
3.1	Is healthcare provided in a close or familiar environment to children (i.e. at home, pre-school, school)?
	If yes, please specify in which settings healthcare is provided
3.2	Do hospitals facilitate the possibility for children to have schooling in hospital?
3.3	When children are receiving health care, are parents or carers allowed, encouraged and helped to stay with the child, unless this goes against the child’s best interest?
3.4	Do health care institutions make the necessary logistic arrangements to facilitate parents or carers to stay with the child receiving health care?
3.5	Do health services work in collaboration with other institutions (i.e. schools, social services, justice system, etc) to ensure the protection of children, address children’s social determinants of health and avoid the medicalisation of social problems?
	If yes, please provide examples
3.6	Are there patient safety measures in place at health service delivery?
3.7	When receiving healthcare, are all children informed about their condition, in a way they can understand?
3.8	Where children are legally entitled to give their consent to treatment, are they always asked to give their consent before an intervention?
3.9	Are children regularly consulted to give their opinion about their experience in health services?
	If yes, is children’s opinion used for the improvement of healthcare delivery?
Capacity building measures for professionals
	Question		Yes					No
4.1	Are all doctors and nurses working with children in Primary Healthcare Services trained in paediatric care?
	If yes, please specify
4.2	Are all health professionals (doctors, nurses, psychologists, play specialists, etc) working with children in hospitals trained in paediatric care?
	If yes, please specify
4.3	Are children’s rights in health a subject integrated in undergraduate and/or graduate Medical curricula?
	If yes, please describe briefly what aspects of children’s rights are taught
4.4	Is communication with children a subject integrated in undergraduate and/or graduate Medical curricula?
National practices which have proven to be effective
Please use this space to register additional national practices relating to the implementation of Child-Friendly Healthcare, which have proven to be effective.

 

Part 3: Explanatory notes

 

For the purpose of the Guidelines:

 

1. A child refers to any person under the age of 18;
2. A parent refers to the person(s) with parental responsibility according to national law. In case the parent(s) is/are absent or no longer holding parental responsibility, this can be a guardian or an appointed legal representative.

 

Question 1.1

 

Explanatory note

 

Member states should review their domestic legislation, to ensure that it is in line with the Guidelines and to adopt legislation, where it is not.

 

Reference

 

In the Preamble of the Guidelines, the Committee of Ministers “adopts the following guidelines on child-friendly health care to serve as a practical tool for the governments of the member states in endorsing, adopting, implementing and monitoring the child-friendly health care approach contained therein and adapting their health care systems for children and families to the specific rights, interests and needs of children.”

 

In the Lisbon Declaration, member states undertake to “strengthen the rights-based approach to children’s health by taking steps to implement the Guidelines on Child-friendly Health Care, adopted by the Committee of Ministers on 21 September 2011.”

 

Question 1.2

 

Explanatory note

 

In the Preamble of the Guidelines, the Committee of Ministers refers to “the necessity of ensuring the effective implementation of existing binding universal and European standards protecting and promoting children’s rights in general, as well as those covering aspects specific to health care.”

 

Reference

 

The binding universal and European standards included in the Guidelines and set out in its Preamble are:

 

• the United Nations Covenant on Economic, Social and Cultural Rights (1966), and in particular its Article 12 on the right to the highest attainable standard of health;
• the United Nations Convention on the Rights of the Child (1989);
• the United Nations Convention on the Rights of Persons with Disabilities (2006);
• the Convention for the Protection of Human Rights and Fundamental Freedoms (1950, ETS No. 5);
• the European Social Charter (1961, ETS No. 35) and the Revised European Social Charter (1996, ETS No. 163);
• the European Convention on the Exercise of Children’s Rights (1996, ETS No. 160);
• the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (1987, ETS No. 126);
• the Council of Europe Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse (2007, CETS No. 201);
• 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 (1997, ETS No.164), in particular its Article 6;

 

The Guidelines also suggest the implementation of:

 

• the Charter for Health Promotion (1986, Ottawa);
• the European Charter for Children in Hospitals (1988, Leiden);
• CoE Guidelines on child-friendly justice, adopted on 17 November 2010;
• CoE Recommendation CM/Rec(2010)2 on the deinstitutionalisation and community living of children with disabilities;
• CoE Recommendation CM/Rec(2009)10 on integrated national strategies for the protection of children from violence;
• CoE Recommendation Rec(98)8 on children’s participation in family and social life;
• CoE Recommendation Rec(2006)7 on management of patient safety and prevention of adverse events in health care;
• CoE Recommendation (2006)5 on the Council of Europe Action Plan to promote the rights and full participation of people with disabilities in society: improving the quality of life of people with disabilities in Europe 2005-2015;
• CoE Recommendation Rec (2000)5 on the development of structures for citizen and patient participation in the decision-making process affecting healthcare.

 

Question 1.3

 

Explanatory note

 

Measures to ensure equitable access to healthcare may include, among other: legislation protecting the access of vulnerable groups of children, such as children living in distant areas from where the health service is located; homeless and street children, children in residential institutions, children with disabilities, etc.

 

Reference

 

In the Lisbon Declaration State Parties agree to progress towards equitable access to quality health care services for all children.

 

Paragraph 9 of the Guidelines states that “the rights of children shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.”

 

Paragraph 13 of the Guidelines states that “all children should have equitable access to quality health care services. This includes prevention, promotion, protection and provision of services with the active involvement of children.”

 

Other paragraphs of the Guidelines explain the meaning of accessible healthcare, which include, among other, physical access (paragraph 50) and affordable healthcare services (paragraph 38.i.), as below:

 

• “Health care should be readily accessible to the population. Where possible, care should be delivered close to the child’s home or in a familiar environment, for example in pre-school or school, where the child feels comfortable and where care can be delivered in partnership with his or her parents or carers. Where care needs to be delivered in hospital, the environment should be adapted to meet the needs of the child (paragraph 50)”;
• “a comprehensive range of services which both promote and protect their health, coupled with timely, accessible and affordable services when problems occur” (paragraph 38.i.);

 

Question 1.4

 

Explanatory note

 

Vulnerable children are more likely to have difficulties in accessing health services and benefit from existing services due to a variety of factors. For this reason, often additional measures are needed to ensure that they have equal access to quality healthcare services.

 

Reference

 

Paragraph 14 of the Guidelines states that “specific health care provision may be needed for more vulnerable children, such as children with disabilities, children in residential institutions, homeless and street children, children living in low-income families, Roma children, migrant children, refugee and asylum-seeking children, unaccompanied children and abused and neglected children.”

 

Question 1.5

 

Explanatory note

 

Criteria for children’s informed consent to treatment can be based on:

• the child’s age, for example, all children from 16 years old can give consent to treatment themselves;
• the child’s maturity, for example, all children that are considered competent, independently of their age and are able to understand the treatment and consequences, can give consent to treatment themselves.

 

Reference

 

In the Lisbon Declaration State Parties agree “to progress towards facilitating the implementation of the principle in Article 6 of the Oviedo Convention with regard to the child’s participation in medical decisions.”

 

Article 6, paragraph 2 of the Oviedo Convention states: “Where, according to law, a minor does not have the capacity to consent to an intervention, the intervention may only be carried out with the authorization of his or her representative or an authority or a person or body provided for by law. The opinion of the minor shall be taken into consideration as an increasingly determining factor in proportion to his or her age and degree of maturity”.

 

Question 1.6

 

Explanatory note

 

Children’s participation in healthcare should not be limited to the right to informed consent to treatment. Children’s participation in matters that affect their own health may include, among other, the right to receive information according to their evolving capacity, the right to ask questions and to have their views taken into account, even when children do not have the right to informed consent as such. Children should also be involved in the design, development and assessment of healthcare services. This participation may include the participation in consultations on what services are needed and where, participating in patient satisfaction surveys or other.

 

Reference

 

Paragraph 62 of the Guidelines states that member states should support programmes and policies aimed at raising the awareness of children and their parents of their rights to active participation in decision making and the promotion and protection of their health, by creating legal structures and policies that support the promotion of children’s rights in health care, if these do not already exist.

 

Furthermore, “participation in healthcare should be exercised at three levels:

 

i.individual decision making, whether this be lifestyle choices or involvement in medical decision making. Implementation will require accessible information, clinical staff able to communicate with children and measures for mediation when differences occur (Guidelines, Paragraph 42.i.). When a child, according to law, is able to consent to an intervention, the intervention may only be carried out after the child has given his or her free and informed consent. When, according to law, the child does not have the capacity to consent to an intervention, the opinion of the child shall be taken into account as an increasingly determining factor in proportion to his or her age and degree of maturity (Guidelines, Paragraph 12.i.);

 

ii.children should be given the opportunity to provide feedback on their experience after they have used services. Implementation will require the development of assessment of both patient-reported outcome and patient-reported experience and different methods of involving them in the process (individually and with peers) (Guidelines, Paragraph 42.ii.);

 

iii.with increasing maturity and capacity, children should be involved in the policy/planning process for the services they use. Children should be considered as active members of society, and not as mere passive subjects of decisions taken by adults. This implies, taking into consideration their age and degree of maturity, their being informed and consulted, and given the opportunity to take part in social decision-making processes on health care issues, including the assessment, planning and improvement of health care services. Implementation will require appropriate training/learning opportunities to enable them to participate in this process, for example understanding priority setting (Guidelines, Paragraphs 12.ii and Paragraphs 12.ii and 42.iii.).”

 

 

Question 1.7

 

Explanatory note

 

National guidelines and protocols may be adopted in relation to common childhood diseases or specific aspects of child health (adolescent health, health promotion, prevention of illness, pain management, unnecessary hospitalization, etc).

 

Reference

 

Paragraph 53 of the Guidelines states that “it is essential to integrate a culture of learning and improvement into service delivery. Each agency should have a similar approach to the choice of evidence-based interventions, priority setting, maintaining staff competence, working in teams and continuous quality improvement.”

 

The Lisbon Declaration states that member states are “resolved to progress towards evidence-based interventions by professionals with appropriate competences, dedication and knowledge of child-specific physical and well-being needs, as well as their psycho-social situation.”

 

Question 1.8

 

Explanatory note

 

Monitoring legislation is an essential component to ensure compliance with any adopted standard. In order to assess the implementation of a standard or right, goals, actions and indicators must be developed. Monitoring and evaluating enables member states to identify good practice, gaps and monitor progress and achievement.

 

Reference

 

Paragraphs 57 and 65 of the Guidelines call for the need measure and monitor the implementation of the child-friendly health care approach in their health care policies and practice.

 

Question 1.9

 

Explanatory note

 

Budget for specific Child-Friendly Healthcare activities can be allocated from the regular ministerial/health service budget or, for instance, be allocated via Calls for Funding directed at NGOs working on different aspects of Child-Friendly Healthcare.

 

Reference

 

Paragraphs 18 and 64 call the attention of member states to make resources available for the investment in services for children.

 

Question 2.1.

 

Explanatory note

 

Information is a key strategy in policy-making and in the delivery of services. Children and parents should be informed about their rights and what services are available to them, as well as, the contents of key policy documents. On the other hand, the authorities working with and for children should be informed and trained on how to use the different legislation and policy documents.

 

Reference

 

In the Preamble of the Guidelines, the Committee of Ministers “invites the governments of the member states to ensure that the guidelines are widely disseminated among all authorities, service providers, groups representing the interests of children and families and other stakeholders responsible for or involved with children’s rights, particularly in health care.”

 

Question 2.2

 

Explanatory note

 

Member states should take steps to adopt the Child-Friendly Healthcare approach as set out in the Guidelines and translate it into actions, at policy and health delivery level.

 

Reference

 

In the Preamble of the Guidelines, the Committee of Ministers “adopts the following guidelines on child-friendly health care to serve as a practical tool for the governments of the member states in endorsing, adopting, implementing and monitoring the child-friendly health care approach contained therein and adapting their health care systems for children and families to the specific rights, interests and needs of children.”

 

Question 2.2.1

 

Explanatory note

 

“Health promotion is “the process of enabling people to increase control over their health and its determinants and thereby improve their health”.[1] Promotion therefore includes all actions that allow children to become more involved in their own health and increase their exposure to positive determinants of health (defined as factors which will improve health or well-being). Health promotion covers not only activities in families and communities, directed at health determinants or lifestyles, but also factors in health care services and settings which will improve outcomes (Guidelines, paragraph 25.).” 

 

Reference

 

The Guidelines explain that “effective health promotion requires synergy between evidence-based interventions at a number of levels simultaneously. It is relevant to all children, particularly the most vulnerable, and those using health services:

 

i.All children. All children should participate in health-promotion programmes and policies, such as child-friendly cities, child-friendly schools, and child-friendly child care (Guidelines, paragraph 43.i.);

 

ii.Vulnerable children. The determinants of health are not equally distributed among children in society, whether they be social, emotional or financial. Where there is poor parental health, especially mental health, learning difficulties or substance abuse, children will require additional targeted support to enable them to reach their maximum potential. Implementation will require a variety of evidence-based interventions being accessible (Guidelines, paragraph 43.ii.);

 

iii.Children using health services. Where children have repeated or long-term contact with health services, for example with complex illness, head injury rehabilitation or severe mental health problems, it is imperative that they maintain contact with their families and their friends and that their education or future health is not impaired through a prolonged stay in hospital (Guidelines, paragraph 43.iii.).”

 

Question 2.2.2

 

Explanatory note

 

“Health protection includes all actions that either limit or avoid children’s exposure to any hazard which can be defined as a factor that has the potential to cause harm. Hazards can occur in families, communities and health services. Medical interventions can cause harm and patient safety perspectives highlight the fact that children are particularly vulnerable to medication errors and hospital-acquired infections (Guidelines, paragraph 26.).”

 

Reference

 

The Guidelines provide that ”children who use health services should be protected from either deliberate or unintended harm while using services:

 

i.All children. All children require protection from physical, social, emotional or financial harm. Implementation will require interventions to improve the physical environment (for example, the quality of housing, air quality, reducing the risk of injuries and preventing violence), to improve the social environment by improving parents’ parenting capacity, to prevent bullying or racism and to support families on low incomes (Guidelines, paragraph 45.i.);

 

ii.Vulnerable children. Children with long-term conditions, whether illness or disability, require special protection from the recognised hazards that might affect them (Guidelines, paragraph 45.ii.);

 

iii.Children using health services. All interventions and systems have the potential to cause harm and/or adverse effects. Children are often at greater risk than adults due to their immaturity and less developed language and communication skills. Implementation will require the development of a coherent and comprehensive patient-safety policy framework, including a child-friendly reporting system for adverse events in order to learn from such incidents. Professionals working with and for children should, where necessary, be subject to regular vetting, according to national law, to ensure their suitability to work with children (Guidelines, paragraph 45.iii.).”

 

Question 2.2.3

 

Explanatory note

 

“Prevention is an active process the aim of which is to avoid future health, social or emotional problems in order to enable the fullest realisation of human potential. This includes action to reduce adverse health determinants, to prevent the development of a disease or condition, to avoid complications of a disease or condition, to prevent the impact of a disease or condition on the lifestyle or aspirations of an individual and to prevent harm caused by a service or intervention (Guidelines, paragraph 27).”

 

Reference

 

The Guidelines explain that “prevention can take place at three levels:

 

i.primary prevention includes mainly population-based interventions such as vaccination programmes, the prevention of dental caries through fluoridation of water supplies, or the prevention of neural tube defects through folate supplementation in cereals (Guidelines, paragraph 46.i.);

 

ii.secondary prevention may be population-based, such as the early detection of deafness through neonatal hearing screening programmes, or targeted towards specific groups of children to prevent, for example, the secondary complications of diabetes, or hip dislocation in children with cerebral palsy (Guidelines, paragraph 46.ii.);

 

iii.tertiary prevention requires interventions to prevent secondary disabilities or deficiencies arising from established medical conditions (Guidelines, paragraph 46.iii.).

 

Implementation of the approach is on two levels. Member states should decide which promotion and prevention programmes should be implemented on the basis of the entire population and which should be targeted at a selected population of children. At an individual level, health professionals, children and their families should proactively plan the management of a child’s condition, recognising the likely complications or associated disabilities and thereby reduce their impact on the child’s quality of life and everyday living (Guidelines, paragraph 47).” 

 

Question 2.2.4

 

Explanatory note

 

“Provision refers to any service which contributes to the health and well-being of children and families, and therefore includes more than just traditional health services. “Pathway-based provision” is a concept that describes all the component parts that need to be in place and working well together to achieve an excellent patients’ experience which brings about optimal outcomes for children and families in their journey safely through services (Guidelines, paragraph 28.).”

 

Reference

 

The Guidelines explain that the ”implementation of the approach will require applying evidence-based and user-friendly guidelines for health professionals and families and make this evidence easily available to create an alignment of clinical expectations between patients and carers. Maintaining the competence of individuals working with children and families requires initial “child-friendly health care” training, support for staff implementing innovative measures in order to create child-friendly health care, and rewards for doing so. Likewise, assisting children to become “knowledgeable patients” is essential to achieve good outcomes (Guidelines, paragraph 49.).

 

It is essential to integrate a culture of learning and improvement into service delivery. Each agency should have a similar approach to the choice of evidence-based interventions, priority setting, maintaining staff competence, working in teams and continuous quality improvement (Guidelines, paragraph 53.).

 

Feeling safe, secure and comfortable should be part of the child’s therapeutic process. This requires staff to be “child-friendly” and both culturally and clinically competent. Health care should be provided in a “child-friendly” environment, and separately from adults where appropriate. Fear, discomfort and pain should be recognised, assessed and managed using age-appropriate interventions (Guidelines, paragraph 54.).”

 

Question 2.2.5

 

Explanatory note

 

As presented in the Guidelines, children’s social determinants of health may include, but are not limited to, environmental issues (air and water quality, sanitation), socio-economic problems (poverty, social exclusion, poor housing and nutrition), access to education, or parental issues (parenting skills, parents’ mental health, domestic violence or substance abuse).

 

Reference

 

In the Lisbon Declaration State Parties agree “to progress towards working together with other ministries and other relevant stakeholders to effectively address the bio-psycho-social development of every child and the social determinants of health.”

 

Paragraph 33 of the Guidelines provides that “interventions should focus not only on managing the child’s health condition, but also on their physical or social environment, thus avoiding the medicalisation of social problems.”

 

Question 2.2.6

 

Explanatory note

 

Children of different age groups can be consulted through participatory approaches to contribute to the design, planning and assessment of health services. Children should be given the possibility to contribute with their opinions on past experience of health services, services that are needed, expectations and other.

 

Reference

See explanation to question 1.6.

 

Question 2.3

 

Explanatory note

 

Coordination between different levels of government is essential to harmonise legislation, policy and practice, as well as, effective monitoring and evaluation systems.

Referral systems contribute to the cost-effectiveness and efficiency of the health services, by better utilising resources and facilities and providing better care to patients. A referral system should be established and appropriate referral protocols should be readily available for health professionals’ use.

 

Reference

 

The Preamble of the Guidelines emphasise “the need to create coherent policies and synergies towards a co-ordinated approach for children at all levels of government and at all levels of health-service provision in particular.”

 

Paragraph 18 of the Guidelines provides that “achieving improvements is often difficult without a shared approach to the planning and delivery of services, and for the achievement of better value with the combined resources available, it is essential that all services and stakeholders work together.”

 

Paragraph 19 of the Guidelines states the “importance of good co-ordination and continuity of care based on an integrated and multi-disciplinary approach, sometimes referred to as a “continuum of care”. This extends across the traditional boundaries of primary, secondary and tertiary health care organisations, involving health, education, social care and justice systems whether in the public, private or voluntary sectors.”

 

Question 2.4

 

Explanatory note

 

Children’s well-being is dependent upon and influenced by social determinants and services in place in all of children’s life settings. For this reason, organisations and individuals working in each setting play an important role in children’s health and development. Each organisation and individual – parent, school or health care service – should be part of a network working in synergy to contribute to the empowerment and development of children.

 

Reference

 

Paragraph 19 of the Guidelines states “the importance of good co-ordination and continuity of care based on an integrated and multi-disciplinary approach, sometimes referred to as a “continuum of care”. This extends across the traditional boundaries of primary, secondary and tertiary health care organisations, involving health, education, social care and justice systems whether in the public, private or voluntary sectors.”

 

Question 2.5

 

Explanatory note

 

In all member states, private and voluntary sector organisations are working on different aspects of Child-Friendly Healthcare. Member states should establish protocols with them, to benefit from their expertise and enhance action centred on children’s needs, rights and well-being.

 

Reference

 

Paragraph 19 of the Guidelines states “the importance of good co-ordination and continuity of care based on an integrated and multi-disciplinary approach, sometimes referred to as a “continuum of care”. This extends across the traditional boundaries of primary, secondary and tertiary health care organisations, involving health, education, social care and justice systems whether in the public, private or voluntary sectors.”

 

Question 2.6

 

Explanatory note

 

Member states have already adopted legislation, policies and practices that are contributing to the implementation of the Child-Friendly Healthcare approach, successfully. Examples of good practices may include engaging with children for the design, planning and improvement of health services; the provision of child-friendly services; training health professionals on children’s rights; among other actions. The exchange of good practices enables decision-makers and healthcare providers to learn new approaches, adopt tools and enhance mutual learning.

 

Reference

 

Paragraph 66 of the Guidelines provides that member states should “exchange practice and promote international co-operation in the field of child-friendly health care.”

 

Question 2.7

 

Explanatory note

 

Monitoring legislation is an essential component to ensure compliance with any adopted standard. In order to assess the implementation of a standard or right, goals, actions and indicators must be developed. Monitoring and evaluating enables member states to identify good practice, gaps and monitor progress and achievement.

 

Reference

 

Paragraphs 57 and 65 of the Guidelines call for the need “to measure and monitor the implementation of the child-friendly health care approach in their health care policies and practice.”

 

Question 2.8

 

See explanation to question 1.9.

 

Question 3.1

 

Explanatory note

 

Providing healthcare services in various children’s life settings is an effective way to ensure that all children receive the same care and that families are supported. A range of services, approaches and partnerships may be in place to respond to a number of children’s healthcare needs. These may include, among other, supporting mothers in breastfeeding at home; promoting healthy eating habits at schools; implementing partnerships between schools and primary health care services to support children with psycho-social problems, etc. 

 

Reference

 

Paragraph 50 of the Guidelines provides that “health care should be readily accessible to the population. Where possible, care should be delivered close to the child’s home or in a familiar environment, for example in pre-school or school, where the child feels comfortable and where care can be delivered in partnership with his or her parents or carers. Where care needs to be delivered in hospital, the environment should be adapted to meet the needs of the child.”

 

Question 3.2

 

Explanatory note

 

Where children have to face a prolonged stay in hospital, it is important to secure the continuation of their education through a school or teacher in the hospital.

 

Reference

 

Paragraph 44 calls the attention to the “need to offer children the possibility to have schooling in hospital.”

 

Question 3.3

 

Explanatory note

 

Parents are key figures for children in their lives, particularly in times where they feel most vulnerable. Additionally, the nature of the relationship between parent and child means that parents are more knowledgeable about the child’s character, values, assets and needs, which play an important role themselves while children are receiving health care. Due to these reasons, parents can have an important role, particularly if the child is hospitalised. They can comfort their child; help children and health professionals alike, in the preparation of procedures; and learn to manage children’s chronic or other prolonged illness.

 

Parents being allowed to stay with their child means that, by legislation or hospital policy, parents have the right to stay with them during hospitalisation or whilst receiving other health care. Parents being encouraged and helped to stay with their child means that parents are informed about the possibility to stay with their child, health professionals welcome them in the management of their child’s care and, where necessary, parents have the right to paid work leave or similar benefits, to be able to stay with their child.

 

Reference

 

In the Lisbon Declaration State Parties agree to “progress towards parents or carers being allowed, encouraged and helped to stay with the child receiving health care, unless this goes against the child’s best interest.”

 

Paragraph 21 of the Guidelines states that “Child-friendly Healthcare includes the notion of “family-friendly”, facilitating bonding between newborn babies and their mother/parents, facilitating contacts between the child and his or her family and preventing the separation of the child from his or her family unless it is in the best interest of the child.”

 

Question 3.4

 

Explanatory note

 

Parents staying with their child in hospital at all times should include overnight stay. In order to fulfil that right, hospitals must make the necessary arrangements, which may include providing a more comfortable armchair or bed by the child’s bed or other sleeping arrangements in the hospital grounds. Ensuring sleeping arrangements for parents may be particularly relevant for parents who are travelling long distances to visit their child in hospital and/or have little resources to pay for a sleeping arrangement themselves.

 

Reference

 

In the Lisbon Declaration State Parties agree to “progress towards health care institutions making the necessary arrangements to facilitate parents or carers staying with the child receiving health care.”

 

Question 3.5

 

Explanatory note

 

The importance of effective coordination, referral systems and tackling the social determinants of health has been addressed in questions 2.2.5, 2.3 and 2.4. At health service delivery level, it is essential to work in partnership with other sectors to address children’s determinants of health and avoid the medicalisation of social problems.

 

Reference

 

The Preamble of the Guidelines emphasise “the need to create coherent policies and synergies towards a co-ordinated approach for children at all levels of government and at all levels of health-service provision in particular.”

 

Paragraph 19 of the Guidelines states the “importance of good co-ordination and continuity of care based on an integrated and multi-disciplinary approach, sometimes referred to as a “continuum of care”. This extends across the traditional boundaries of primary, secondary and tertiary health care organisations, involving health, education, social care and justice systems whether in the public, private or voluntary sectors.”

 

Paragraph 33 of the Guidelines provides that “interventions should focus not only on managing the child’s health condition, but also on their physical or social environment, thus avoiding the medicalisation of social problems. It includes addressing environmental issues (air and water quality, sanitation), socio-economic problems (poverty, social exclusion, poor housing and nutrition), access to education, or parental issues (parenting skills, parents’ mental health, domestic violence or substance abuse).”
 

Question 3.6

 

Explanatory note

 

Medical interventions can cause harm and patient safety perspectives highlight the fact that children are particularly vulnerable to medication errors and hospital-acquired infections, which children must be protected from.

 

Reference

 

In the Preamble of the Guidelines, the Committee of Ministers recognise that “promoting the health and well-being of children, with particular attention to the safety and quality of services, is important to society as a whole.”

 

Paragraph 45.iii. provides that “all interventions and systems have the potential to cause harm and/or adverse effects. Children are often at greater risk than adults due to their immaturity and less developed language and communication skills. Implementation will require the development of a coherent and comprehensive patient-safety policy framework, including a child-friendly reporting system for adverse events in order to learn from such incidents. Professionals working with and for children should, where necessary, be subject to regular vetting, according to national law, to ensure their suitability to work with children.”

 

Question 3.7

 

Explanatory note

 

Adequate information is the first step to an effective involvement of children in decision-making processes. Children should receive information about what is happening to them, proposed treatments and likely consequences, in a way they can understand. This may include speaking in an accessible language or using visual or written support material, whilst always taking into account the child’s age and evolving capacities.

 

Reference

 

Paragraph 42 of the Guidelines states that “meaningful participation requires children and families to be fully informed about the issues they are considering in order to improve the quality of their decision making. This requires relevant information to be presented in ways appropriate to the level of development and capacity of the child.”

 

Question 3.8

 

Explanatory note

 

All legislation should be translated into practice. Where children have the right to informed consent, they should always be able to exercise that right. Therefore, before any intervention, all children receiving health care should be appropriately informed and asked for their consent to treatment. This consent should be recorded by means of a signed form or registered in a patient chart or other means.

 

Reference

 

Paragraph 12.i. of the Guidelines provides that “when a child, according to law, is able to consent to an intervention, the intervention may only be carried out after the child has given his or her free and informed consent.”

 

Question 3.9

 

Explanatory note

 

Children’s right to participation entails participation in the design, assessment and improvement of services. Children who have received care have direct experience with the healthcare service and thus, will have a valuable opinion about whether it is meeting their needs and expectations. Children can participate in a patient satisfaction survey whilst receiving healthcare, at the end of hospitalisation or once they return home. Children can also participate by means of a group consultation within a specific project aiming at assessing and/or improving healthcare services. The opinions gathered from children should contribute to and be used for the improvement of healthcare delivery. For example, the patient satisfaction questionnaires received during a given year can be included in a hospital’s annual management report to assess hospital performance, set priorities and plan improvements.

 

Reference

 

In the Lisbon Declaration State Parties agree to “progress towards consulting and involving children and, where appropriate, their families, in the planning, assessment and improvement of health care services.”

 

The Guidelines provide that “with increasing maturity and capacity, children should be involved in the policy/planning process for the services they use. Children should be considered as active members of society, and not as mere passive subjects of decisions taken by adults. This implies, taking into consideration their age and degree of maturity, their being informed and consulted, and given the opportunity to take part in social decision-making processes on health care issues, including the assessment, planning and improvement of health care services. Implementation will require appropriate training/learning opportunities to enable them to participate in this process, for example understanding priority setting (Guidelines, Paragraphs 12.ii and Paragraphs 12.ii and 42.iii.).”

 

Question 4.1

 

Explanatory notes

 

All doctors and nurses working with children in primary healthcare services should have received specific training on how to manage childhood diseases and children’s needs and characteristics.

 

Reference

 

In the Lisbon Declaration State Parties agree to progress towards evidence-based interventions by professionals with appropriate competences, dedication and knowledge of child-specific physical and well-being needs, as well as their psycho-social situation. State Parties further agree to facilitate the development of appropriate practical tools for health practitioners to implement the child-friendly health care approach.

 

Paragraph 32 of the Guidelines states that Child-Friendly Healthcare must be delivered by competent practitioners working in teams, provided in the right place and at the right time in order to ensure the right outcomes at the right price.

 

Question 4.2

 

Explanatory note

 

All health professionals working with children in primary healthcare services should have received specific training on how to manage childhood diseases and children’s needs and characteristics. In hospital, this may include doctors, nurses, play specialists and other hospital staff.

 

Reference

 

See Reference above concerning question 4.1.

 

Question 4.3

 

Explanatory note

 

In order to train competent professionals in the Child-Friendly Healthcare approach, it is essential to introduce children’s rights in the Medical curricula, in addition to the management of childhood diseases.

 

Reference

 

In the Lisbon Declaration, member states declare that child-friendly healthcare includes “children’s rights as a guiding principle in the planning, delivery and monitoring of health care services for children.”

 

Paragraph 49 of the Guidelines states that “maintaining the competence of individuals working with children and families requires initial “child-friendly health care” training, support for staff implementing innovative measures in order to create child-friendly health care, and rewards for doing so.”

 

Question 4.4

 

Explanatory note

 

Health professionals must be trained not only in theoretical issues regarding children’s rights, but also practical skills.  Participation is an essential component of the Child-Friendly Healthcare approach. In order for health professionals to be able to implement children’s rights to information and participation effectively, they must be taught about legislation and protocols on informed consent, but also practical skills on how to communicate effectively with children of all ages and capacities.

 

Reference

 

Paragraph 23 of the Guidelines states that “participation means that children have the right to be informed, consulted and heard, to give their opinions independently from their parents and to have their opinions taken into account. It implies the recognition of children as active stakeholders and describes the process by which they take part in decision making. The level of child participation depends both on his or her age, evolving capacities, maturity and on the importance of the decision to be taken.”

 

Question 5

 

Explanatory note

 

Question 5 is intended to enable member states to register good practices relating to the implementation of the Child-Friendly Healthcare approach, which have not been dealt with in any of the above questions.

[1] Health Promotion Glossary, WHO, 1998.