Seventieth Regional Committee for Europe: virtual session, 14–15 September 2020: final reports on Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 and the European Child Maltreatment Prevention Action Plan 2015–2020

W O RL D HE AL TH O R GAN I ZA T I ON RE GI ON AL O FF I CE FO R EU RO PE UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Telephone: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eugovernance@who.int Web: http://www.euro.who.int/en/who-we-are/governance Regional Committee for Europe EUR/RC70/8(L) 70th session Virtual session, 14−15 September 2020 20 August 2020 200597 Provisional agenda item 6 ORIGINAL: ENGLISH Final reports on Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 and the European Child Maltreatment Prevention Action Plan 2015–2020 These progress reports provide an overview of implementation of Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 and the European Child Maltreatment Prevention Action Plan 2015–2020, in line with resolution EUR/RC64/R6. They are submitted to the WHO Regional Committee for Europe at its 70th session in September 2020, in line with resolution EUR/RC64/R6. EUR/RC70/8(L) page 2 Contents Background ................................................................................................................................ 3 Final report on Investing in Children: the European Child and Adolescent Health Strategy 2015–2020.................................................................................................................... 3 Strategies, governance and data ........................................................................................ 3 Early childhood development ........................................................................................... 4 Framework for early childhood development ................................................................... 4 Provision of care ............................................................................................................... 4 Quality of care provided for children ............................................................................... 5 Rights and participation .................................................................................................... 5 Sexual and reproductive health ......................................................................................... 5 Mental health and well-being ........................................................................................... 5 Nutrition and physical activity .......................................................................................... 6 Support for health in the school environment ................................................................... 6 The Health Behaviour in School-aged Children survey ................................................... 6 Providing information to countries and support for strategy development ...................... 7 Other strategies and action plans ...................................................................................... 7 Final report on Investing in Children: the European Child Maltreatment Prevention Action Plan 2015–2020 .............................................................................................................. 8 Objective 1: make violence against children more visible in Member States by setting up information systems ......................................................................................... 8 Objective 2: strengthen governance for the prevention of violence against children by developing national plans, partnerships and multisectoral action ............................... 8 Objective 3: reduce risks and consequences of violence against children by strengthening prevention and health systems ................................................................... 9 Has the European Region achieved the Action Plan’s target of reducing child maltreatment and child homicide rates by 20% by 2020? .............................................. 10 Conclusion and way forward.................................................................................................... 10 Preparing a child and adolescent health strategy beyond 2020 ...................................... 10 EUR/RC70/8(L) page 3 Background 1. At its 64th session in 2014, in resolution EUR/RC64/R6, the WHO Regional Committee for Europe adopted Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 and the European Child Maltreatment Prevention Action Plan 2015–2020. The resolution requested that the WHO Regional Director for Europe report back to the Regional Committee at its 68th and 71st sessions, in 2018 and 2021, respectively, on implementation of both the Strategy and the Action Plan. The midterm report was duly submitted to the Regional Committee at its 68th session in 2018. These final reports provide information on progress made in implementing Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 and the European Child Maltreatment Prevention Action Plan 2015–2020 during the two-year period from 2018 to the conclusion of the Strategy and the Action Plan in 2020. 2. To obtain up-to-date information on the status of child and adolescent health in the WHO European Region, a survey was sent to Member States in November 2019. A total of 45 countries had responded by 30 April 2020, and their responses make up the main substance of this summary report on the Strategy. Annex 1 contains maps showing responses, by country, to selected questions. A complete report with maps and summary tables for all questions and other indicators related to child health will also be made available by the end of 2020. 3. With regard to child maltreatment, this final report on the Action Plan describes outcomes until March 2020, under each of the objectives. This final report is based on the responses of the 45 countries that participated in the European regional status report on preventing violence against children (2020). Indicators of the progress of all stages of implementation are outlined in Annex 2. The European regional status report on preventing violence against children (including country profiles) will be published before the end of 2020. Final report on Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 Strategies, governance and data 4. In 41 of the 45 countries that responded to the survey, national strategies for child and adolescent health have either been adopted or are in preparation. Of the existing strategies, 13 are stand-alone strategies specifically dealing with child and adolescent health. Most of the strategies, however, are part of wider strategies covering the entire population. Fig. A1 (Annex 1)1 compares the responses to this most recent survey to a preceding survey concluded on 31 March 2017. 5. Young people are key stakeholders of national strategies addressing their health, and so it is essential to involve them in the review, development and implementation of these strategies. Eight countries involved children and adolescents in all three stages, while 20 countries involved them in one or two stages (Fig. A2, Annex 1). 6. Of the 45 responding countries, 32 disaggregate health service utilization data by sex, while 35 do so by geographical location. Breaking down the data by migrant status, ethnicity 1 Annexes can be found at https://www.euro.who.int/__data/assets/pdf_file/0005/458573/Annexes-Final- Reports-Investing-in-Children.pdf. EUR/RC70/8(L) page 4 or socioeconomic background is less common: nine countries disaggregate by migrant status, seven do so by ethnicity and 22 do so by socioeconomic background. Only 10 countries provide statistics on the number of unaccompanied, underage migrant or refugee children within their territory (Fig. A3, Annex 1). Early childhood development 7. Early childhood is a critical period that lays the foundations for a healthy start to life and later development. Antenatal and newborn screening programmes are important in the early identification and management of developmental risk factors. Out of the 45 responding countries, 27 provide hearing screening based on objective methods for all infants. Screening for the most common congenital metabolic disorders is provided to a lesser extent. The optimal feeding of young children can be undermined by the unregulated marketing of baby food. Significantly, 75% of responding countries do not collect relevant data on the marketing of complementary feeding products for children aged 6–24 months (Fig. A4, Annex 1). Framework for early childhood development 8. Following a request by Member States in 2017 and after a comprehensive consultation process, the Framework on Early Childhood Development in the WHO European Region2 was developed by the WHO Regional Office for Europe to inform countries of the measures they can take to enable all young children to reach their full potential. The Framework was finalized in February 2020. Provision of care 9. The primary care provider for sick children aged under five years was reported to be a paediatrician in 17 of the 45 responding countries and a general practitioner in 11; primary care is provided through a mixed system in the remaining countries (Fig. A6, Annex 1). Twenty-nine countries reported having guidelines for paediatric palliative care (Fig. A7, Annex 1). Twenty-six countries coordinate plans across multiple sectors for the provision of care for children with complex needs. 10. Five of the 45 responding countries collect data on out-of-pocket payments for the care of children and adolescents (Fig. A9, Annex 1). Similarly, five countries collect data on informal payments to health providers (Fig. A10, Annex 1). The average salaries of general paediatricians, general practitioners/family doctors and nurses vary considerably across the European Region; low salaries may in part be contributing to the prevalence of out-of-pocket and informal payments in some countries. 11. Of the 45 responding countries, 39 had a list of reimbursable medicines, while 33 reported including antibiotics in a paediatric formulation. With regard to emergency treatments, 25 countries reported that diazepam or equivalent drugs are available for children in their primary health care facilities. In 25 countries, dental care for children is fully covered under national health insurance programmes; partial coverage was reported by 14 countries. 2 The Framework on Early Childhood Development in the WHO European Region is available at https://apps.who.int/iris/handle/10665/332068. EUR/RC70/8(L) page 5 Quality of care provided for children 12. Assessments of the performance of health systems using a tracer methodology have been carried out in nine countries. The objective was to determine which health services are available to children and adolescents as part of universal health coverage, and whether those services actually reach those for whom they are intended. A key finding was the high level of out of pocket and often also informal payments. Policy discussions were initiated in the countries in question to address this and other findings. Further assessments are under way. 13. Non-evidence-based practices persist in the provision of health care for children, particularly the indiscriminate use of antibiotics, inappropriate medicalization leading to unnecessary treatment and hospitalization, and the lack of promotion of and support for healthy growth and development. To tackle this problem, a Pocket book of primary health care for children and adolescents and a related smartphone app have been developed by the Regional Office. The pocket book, which is expected to be available by the end of 2020, compiles evidence-based guidance in a user-friendly format for primary health care providers. It is based on existing WHO guidance, which has been adapted to meet the needs of the European Region. The pocket book will provide a solid basis for upholding standards of care in universal health coverage and for designing benefits packages under health insurance programmes. Rights and participation 14. Of the 45 responding countries, 16 reported that 18 years was the age at which adolescents could access health care without parental consent; in 10 countries the age threshold was 16 years, in four countries it was 15 years, and in five countries it was 14 years. Ten countries reported providing access to health care without parental consent, taking into account the degree of maturity of the minor (Fig. A11, Annex 1). Information on the health of migrant and refugee children was collected systematically by 16 countries. Seven countries that in 2017 reported not collecting such information were doing so in 2020. Sexual and reproductive health 15. Of the 45 responding countries, 37 reported having a policy for sexuality education in schools. Adolescents under the age of 18 years have legal access to contraceptives without parental consent in 33 countries (Fig. A13, Annex 1). Data from the 2017/2018 Health Behaviour in School-aged Children (HBSC) survey indicate that one in four boys and one in seven girls aged 15 years report having had sexual intercourse. Of these, one in four had used neither a condom nor the contraceptive pill at their last sexual intercourse. Mental health and well-being 16. Thirty-eight countries consider adolescent mental health to be a key challenge. The 2017/2018 HBSC survey suggests that one in four adolescents feel nervous or irritable or have difficulties getting to sleep every week. The lack of data for important mental health indicators is, however, a problem. Few countries were able to provide information on prescriptions for mental illnesses (12 for attention deficit hyperactivity disorder, nine for autism spectrum disorder and 12 for depression) or on the rates of treatment of these conditions. 17. Thirty-three countries have community-based early intervention programmes for young people experiencing a first episode of a severe mental health problem such as psychosis EUR/RC70/8(L) page 6 (Fig. A14, Annex 1). Of the 16 countries that in 2017 reported not having such programmes, seven now report that they do. A mechanism for the intersectoral planning and monitoring of child and adolescent mental health services was reported to be in place in 17 countries. Nutrition and physical activity 18. In 30 out of the 45 responding countries, marketing to children is regulated; four countries report having plans to implement relevant regulations. Eight countries specifically address marketing via mobile phones and online gaming platforms in their legislation. 19. Thirteen countries have not implemented legislation to combat the availability in schools of foods high in sugar, salt and fat content. Twelve countries allow unhealthy foods, such as soft drinks, sweets and chips, to be sold in schools via vending machines (Fig. A15, Annex 1). The data from the 2017/2018 HBSC survey point to an increasing prevalence of poor eating habits, a decline in physical activity and a rise in adolescent overweight and obesity since 2014, which suggests that insufficient progress has been made in the implementation of relevant policies. Support for health in the school environment 20. Of the 45 responding countries, 30 have a strategy to establish and encourage health promoting schools. Of the 16 countries that in 2017 reported not having such a strategy, six now report having one. Thirty-two countries have a curriculum for health education in schools, while 24 countries have a policy on employing nurses in the school environment. Forty countries reported that school-age children underwent routine health assessments. 21. The WHO-associated Schools for Health in Europe network, which is active in 38 European countries, aims to turn every school in the region into a health promoting school. The network held a European Conference on Health Promoting Schools in Moscow, Russian Federation, in 2019 and is supporting relevant improvements in several eastern European and central Asian countries. The Health Behaviour in School-aged Children survey 22. The Regional Office’s HBSC study has been providing insights into the health behaviours and well-being of adolescents for over 30 years. Surveys are undertaken every four years, the main objectives being to strengthen data collection in the Region and to inform policy design and implementation. Since the adoption of Investing in Children: the European Child and Adolescent Health Strategy 2015–2020 in 2014, seven new countries (Azerbaijan, Cyprus, Georgia, Kazakhstan, Kyrgyzstan, Serbia and Uzbekistan) have joined the study, leading to a total of 46 participating countries in the Region (Fig. A16, Annex 1). 23. The report presenting the findings of the 2017/2018 HBSC survey was launched in May 2020. It provides summary data for the Region as a whole and key data for each country. The data set is publicly available through WHO’s European Health Information Gateway. Most countries participating in the survey have also published national reports. The HBSC report highlights trends in adolescents’ health and well-being. Challenges remain in terms of mental health, risk-taking and exploratory behaviours, physical activity, nutrition, and overweight and obesity. Nevertheless, drinking and smoking among adolescents have both declined since 2014. EUR/RC70/8(L) page 7 Alcohol remains the most commonly used substance (37%). Problematic use of social media at the age of 15 years is more common among girls than boys (10% versus 7%). Providing information to countries and support for strategy development 24. The findings of the 2018 progress report, contained in document EUR/RC68/8(E), were converted into country profiles. Publicly available information was subsequently added to these profiles, with the focus being on the priorities set out in Investing in Children: the European Child and Adolescent Health Strategy 2015–2020. The profiles have been shared with Member States; they form the basis of the development of national strategies and can all be accessed through the European Health Information Gateway.3 Several Member States have requested WHO’s support in the development of national child and adolescent health strategies, namely the Republic of Moldova, Romania, Tajikistan, Turkmenistan, the United Kingdom of Great Britain and Northern Ireland (Scotland) and Uzbekistan. Tools to support the preparation of national strategies have been developed by the Regional Office. The WHO collaborating centres for child and adolescent health in Germany, Ireland, Italy, Norway, the Russian Federation, Switzerland and the United Kingdom have contributed significantly to the implementation of the European Child and Adolescent Health Strategy. Other strategies and action plans 25. The 2030 Agenda for Sustainable Development and its accompanying Sustainable Development Goals were adopted by all United Nations Member States in 2015. The Regional Office mapped the European Child and Adolescent Health Strategy against that framework. A version of the Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance adapted for the European Region was launched; it is designed to support Member States with the implementation of measures at the national level to promote adolescent health. The Regional Office is now placing a stronger focus on early childhood development. Accordingly, it recently published the Framework on Early Childhood Development in the WHO European Region. 3 See: https://gateway.euro.who.int/en/datasets/cah/. EUR/RC70/8(L) page 8 Final report on Investing in Children: the European Child Maltreatment Prevention Action Plan 2015–2020 Objective 1: make violence against children more visible in Member States by setting up information systems 26. Of the 45 responding countries, 31 reported having conducted national surveys on the prevalence of violence against children. A further six countries reported that they had yet to conduct such a survey. 27. One-off surveys of adverse childhood experiences have been undertaken in at least 17 countries. In 13 countries, these surveys were supported by the Regional Office, and multisectoral policy dialogues were held to disseminate the results and recommend the next steps for preventive action. Four countries incorporated elements of their surveys on adverse childhood experiences into the surveys that they conducted in 2018/2019 as part of the Regional Office’s HBSC study. 28. Together with relevant WHO collaborating centres, the Regional Office has conducted innovative research aimed at estimating the cost to the Region of not preventing adverse childhood experiences. The total annual health system cost for the Region that is attributable to such experiences was estimated at US$ 581 000 million. 29. A more concerted and coordinated approach is required to ensure that trends in the incidence and 12-month prevalence of all types of violence against children in a given population can be routinely determined. Such an approach would involve, among other things, prioritizing child-friendly victim reporting mechanisms in health, police and social services and regularly conducting standardized and nationally representative household surveys. 30. Standardized methodologies for such surveys have been developed by the United States Centers for Disease Control and Prevention and the United Nations Children’s Fund (UNICEF). Household surveys of this kind have been extensively used in other WHO regions, but in the European Region only the Republic of Moldova has so far completed such a survey, namely in 2019. 31. To maximize the value of all information gathered on the prevalence and incidence of violence against children, such information must feed into the development and implementation of evidence-based interventions and strategic plans. Objective 2: strengthen governance for the prevention of violence against children by developing national plans, partnerships and multisectoral action 32. Multisectoral national or subnational action plans for the prevention of violence against children are currently in place in 34 of the 45 responding countries. Of these 34 countries, 33 have national action plans, while the remaining country has a subnational action plan. Twenty-eight action plans cover all forms of violence against children; 27 are funded by government sources (of which 13 are also funded by international donors); and nine plans define measurable targets. EUR/RC70/8(L) page 9 33. Progress has been made in amending and adopting legislation to prevent violence against children. A total of 33 countries reported having banned the use of corporal punishment against children in all settings. A further eight countries have introduced bans, but these do not apply to all settings (for example, corporal punishment is banned in schools but permitted in the family home). Three countries reported not having any legislation in place forbidding the use of corporal punishment against children. Given that all Member States in the European Region have ratified the United Nations Convention on the Rights of the Child, those European countries that do not have comprehensive legislation against corporal punishment, along with associated enforcement mechanisms, are failing to comply with their obligations under the Convention. 34. In some countries where legislation is in place, a large proportion of children and parents nevertheless continue to report the use of physical punishment.4 It is essential to step up efforts to change the attitudes of parents and caregivers with regard to the use of violence and to raise their awareness of the benefits of non-violent, positive parenting. 35. All 45 responding countries reported having legislation in place that criminalizes sexual violence against children (statutory rape). 36. In a reflection of the importance of collaborative action for the prevention of violence against children at the subnational level, the WHO European Healthy Cities Network established a task force on the trauma-informed prevention of adverse childhood experiences in November 2019. Objective 3: reduce risks and consequences of violence against children by strengthening prevention and health systems 37. The Regional Office’s efforts to support Member States in scaling up intersectoral action for the prevention of and response to violence against children have been based on disseminating the recommendations contained in INSPIRE: seven strategies for ending violence against children. This technical package is the result of collaboration between several agencies and entities, including the Global Partnership to End Violence Against Children. 38. WHO is a founding member of the Global Partnership. Six of the Partnership’s pathfinding countries are located in the European Region: Armenia, France, Georgia, Montenegro, Romania and Sweden. Moreover, Estonia, Finland and Portugal have formally expressed their interest in becoming pathfinding countries. In the European Region, WHO relies on and continues to engage with pathfinding countries for the leadership they bring to regional action. 39. As far as prevention efforts are concerned, good progress has been made: of the 45 responding countries, 34 implement parenting programmes and 36 implement home visiting programmes to support families in need; 31 countries reported that they teach children to recognize and avoid sexually abusive situations; 38 countries provide school-based life and social skills training; 38 countries have operational child protection services; 38 countries carry out systematic identification and referral of cases of violence against children; and 37 countries provide mental health services for child victims of violence. 4 See the UNICEF Multiple Indicator Cluster Surveys at http://mics.unicef.org/. EUR/RC70/8(L) page 10 Has the European Region achieved the Action Plan’s target of reducing child maltreatment and child homicide rates by 20% by 2020? 40. To effectively measure changes in the 12-month prevalence of violence against children, countries (or subnational jurisdictions) must conduct repeated population surveys at regular intervals. Unfortunately, such surveys are not routinely carried out by any country in the European Region. 41. Data on child homicides are more readily available, though it must be pointed out that they are only partly indicative of the true burden of violence against children and it is important to bear in mind various challenges related to timeliness and completeness in the collection of such data. The 2015 data from the European Mortality Database indicate a reduction of 13.6% in homicide rates among children aged 0–14 years (based on a three-year moving average) compared with 2010. Trend projections suggest that the Region is on track to meet and even surpass the Action Plan’s target. Despite the progress made, inequalities do still persist across the Region. In 2014, the homicide rates among children aged 0–14 years were 0.30 per 100 000 in the Region as a whole, 0.24 in the European Union and 0.45 in the Commonwealth of Independent States. Conclusion and way forward 42. The information contained in these two progress reports is publicly available through WHO’s European Health Information Gateway. It should help decision-makers to identify gaps in their national approaches to child and adolescent health and well-being and to the prevention of and response to violence against children, which they may wish to review and tackle. WHO stands ready to support Member States in their efforts to that effect. Preparing a child and adolescent health strategy beyond 2020 43. In 2018 the Regional Office initiated the development of the next European strategy for child and adolescent health, covering the period up to 2030 and in line with the Sustainable Development Goals, the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), WHO’s Thirteenth General Programme of Work, 2019–2023, and the European Programme of Work, 2020–2025 – “United Action for Better Health in Europe”. This will be a whole-of-region strategy, consolidating the work of all regional programmes as it pertains to children and adolescents. 44. To guide the development process, youth engagement experts from across the European Region – from Armenia, Denmark, Ireland, Poland, Portugal, the Republic of Moldova and the United Kingdom (Scotland) – consulted with around 350 children and young people aged between 9 and 23 years on their priorities for child and adolescent health. The central theme emerging from their responses was the need for a stronger focus on mental health and well- being. Family relationships and leisure time were also of high importance. Many young people pointed out how countries needed to adopt a more sustainable lifestyle and take action aimed at tackling climate change, reducing air pollution and promoting a cleaner environment. A mechanism is being set up to provide for the ongoing engagement and consultation of young people across the Region. EUR/RC70/8(L) page 11 45. The COVID-19 pandemic has highlighted additional shortcomings in the European Region’s current approach to child and adolescent health that will need to be addressed in the development of the new strategy. = = =