COVID-19: The right of street children to the highest attainable standard of health

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Introduction
During a pandemic, the ability to access health care and services without discrimination is an obvious requirement to be able to survive, and to survive in good health. While no government can guarantee individual good health for everyone, every government does have obligations to allow people to enjoy the highest attainable standard of health they can, given their individual conditions. While governments are not obligated to provide health services that are beyond their scientific capacity or available resources, they are required to make all health services available to everyone, without discrimination. Access to affordable and quality health care is a fundamental right of every individual; and, is something governments must protect and promote, especially during times of a pandemic.

However, during the COVID-19 pandemic, health systems around the world have come under unprecedented pressure. Within the context of overstretched health resources, what does this right mean for street-connected children and homeless youth? What can CSC Network Members do, who work daily with street-connected children and homeless youth? How can they advocate with governments for protection of these right?

We explain the different ways in which the COVID-19 pandemic affects street-connected children and homeless youth, and what organizations can ask from governments to ensure that they can enjoy their right to the highest attainable standard of health. A section with additional information explaining what the right to health is and what government’s obligations are can be found at the end of this document.

During a pandemic, preserving, protecting and promoting a child’s right to health is, and must be, a priority for everyone. Every child needs to have access to adequate healthcare and health education to protect themselves and others from the virus, including street-connected children.

How are street-connected children and homeless youth affected?

The pandemic has highlighted stark inequalities between people – and one of the starkest has been the extent to which people are able to enjoy their right to health. Especially, considering street-connected children and homeless youth continue to struggle to access basic health services.

Although most children who contract COVID-19 seem to endure mild or no symptoms,(i) children who spend large parts of their lives on the streets may be more at risk than most. Existing health inequalities contribute to both the risk of exposure, as well as the susceptibility to disease during this pandemic (ii). Many health issues that street-connected children normally face could also contribute to their vulnerability during the COVID-19 pandemic.

Due to their extreme poverty and the circumstances in which they live, street-connected children and homeless youth are among the most exposed to the risk of contagion. Their living conditions often do not allow physical distancing or self-isolation. The lack of access to sufficient clean water makes good hygiene practices difficult.

In addition, many street-connected children and homeless youth commonly suffer from underlying health conditions. Infectious diseases, including respiratory infections such as pneumonia, have been shown to be more prevalent among children who live on the street than among their peers who live in a house.(iii) Asthma, a known pre-condition increasing the likelihood of developing more severe COVID-19 if infected,(iv) is also common among street-connected children and the homeless youth. For instance, a study in New York found that homeless youth were hospitalised with asthma at a rate 31 times higher than other youth.(vvi) Poor nutrition, a problem faced by many street-connected children, can weaken the body’s immune response and increase health vulnerabilities. This issue has been exacerbated by the disruption or suspension of many nutrition programmes, such as through school lunches, that otherwise cater for vulnerable children.

Children’s mental health may also suffer as a result of the pandemic. CSC Network Members around the world have expressed concern that their governments are overlooking the psychological impact the pandemic has on vulnerable children such as street-connected children and homeless youth. In Uganda, Dwelling Places reported that when the government announced the lockdown, it caused panic among street-connected children forcing some of them who have homes to start walking back to their villages, many of which are over 200km away from Kampala. SASCU, another organisation in Uganda, reported that the street-connected children they interviewed feel mentally tortured and are living in fear. The Concerned for Working Children operating in Karnataka, India, underlines that fear of uncertainty about potential access to basic needs such as food, housing and medical services, will affect in particular children working on the streets. These will be children who fall out of the protective measures, as well as children dismissed from care institutions due to the coronavirus outbreak, including children who are mentally disabled. The organisation has urged the government to take action to prevent these vulnerable children from being further traumatised.

Finally, as explained in our previous note on access to information, many street-connected children are not protected because they do not have access to appropriate health information. Most of these children do not have access to television or internet, which are the most common means of communication that governments in various countries use to share information and health education. Even when they do have access to information, they may not be able to understand it because it is not tailored to children, does not take into account low literacy levels, or is not translated to relevant languages they understand.

Finally, in the case of street-connected children and homeless youth, legal identity documents are significant barriers to equal access to health care. In most countries, accessing health services requires proof of identity, something many street-connected children and homeless youth are unable to do, as they do not have the necessary documents. In the context of a pandemic, where access to health care is more important than ever, governments should explore innovative and flexible solutions to remove this barrier to accessing basic health services.

What to demand or request from your government?
Governments worldwide are putting in place measures to promote access to health services and health education for everyone, including vulnerable population groups. Some examples of good practices by governments targeting vulnerable children include:

The Ministry of Health, Malawi, with the support of United Nations agencies (including the World Health Organisation, UNICEF, UNAIDS and UN Women) and funded by UK Aid, has provided health workers operating in UNICEF-supported districts with specialised training to deliver special protection to children amid the COVID-19 pandemic. The Ministry has also distributed health-related posters and leaflets across Mwanza, Mchinji and Blantyre markets, targeting the health education of the most vulnerable people where they live.(viii)
On 24th April, the British Government announced the disbursement of £12million on 14 new projects across the country that aim to provide extra support to vulnerable children and young people, such as children in care and children in conflict with the law. The package also includes the improvement of mental health services. The Government has also set out a series of measures to support additional funding to existing services, such as the NSPCC helpline, dedicated to children and young people at higher risk of neglect, abuse and exploitation.(ix)

Most public health initiatives that governments have rolled out, however, do not specifically target street-connected children and homeless youth, and instead street-connected children and homeless youth often fall out of the scope of government emergency programmes.

These are some examples of what you can ask your government to do to ensure that street-connected children and homeless youth can enjoy their right to health. Remind your government that:

They have an obligation to ensure equal access to health care for everyone in the population, and to prioritise interventions that promote access to health care for the most vulnerable in society, including street-connected children and homeless youth.
Poverty cannot be a barrier to receiving medical assistance, including essential medicines, and hospital care, especially during time of a pandemic.
As part of the government’s obligation to uphold equality, recommend your government to allow children to access health care services even if they are not able to provide legal identity documents or have a caregiver present. You can ask your government to collaborate on innovative and flexible strategies for street-connected children and homeless youth to prove their identity when they need to access health care services. For example, the children that you are working with could be identified with provisional ID documents or other systems of identification that could link them to your organisation.
They should not penalise or sanction, but rather support you in assisting street-connected children and homeless youth during this health emergency. If your government puts in place policies that, even indirectly, limit your ability to provide children and their families with essential medicines, or to connect them with medical staff, remind them that they, too, have a duty to protect them.
They have a duty to provide children with equal access to health-related education and information. As explained in our previous note on access to information, knowledge and understanding of the disease and protective measures are crucial to protect and prevent it. Governments should make this information accessible and understandable to street-connected children and homeless youth, including those with low literacy levels.
To include children in street situations in their monitoring, prevention and control programmes. Remind your government that the collection of data is crucial to building an effective response to the pandemic. Excluding children from such programmes undermines the effectiveness of their response, along with negatively impacting their health.
Street-connected children have a right to be heard on all matters that affect their development, including health issues. Street-connected children are experts of their own lives and their views must be considered by policymakers to design an effective response to the emergency, which is tailored to the needs of the specific communities it addresses.

Why should my government listen to these recommendations and implement them?

The right to health is a human right that every individual has, including street-connected children and homeless youth. It is widely recognised in International Law.(x) Article 12 of the International Covenant on the Economic, Social and Cultural Rights (ICESCR) recognises the right of everyone to enjoy the highest attainable standard of health.(xi)

In particular, the Convention on the Rights of the Child (Article 24) says that every child has the right to the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.(xii) The notion of health can be broken down in the following four key features.

First, the child’s right to health means that every child has the freedom to make choices about his or her own body. This includes the ability to make decisions concerning his or her health. It also means that no one should take this right away from her or him for any reason.

Second, the right to health is not just about absence of illness – it is a state of complete physical, mental and social well-being. When it comes to children, many things can affect a child’s well-being. For example, food and water help children grow strong, a safe house and a supportive environment help them grow happy. As we saw in our previous note, knowledge and understanding are also crucial to make good decisions about health. All these things are health determinants, included in the right to health, because without them the right to health cannot be realised.

Third, we talk about the right to the highest attainable standard of health, and not simply the right to health, as staying healthy forever is a promise impossible to uphold. However, while governments cannot guarantee that every child is healthy all the time, it must guarantee that all children are the healthiest they can get. The right to the highest attainable standard of health is, therefore, the right of every child to enjoy the same opportunities to be healthy.

Finally, the right of the child to access facilities for treatment of illness and rehabilitation of health means that health services must be available, accessible, acceptable and of good quality for all children, including street-connected children. These are recognised elements of the right to health and mean the following:

A child cannot stay healthy, without good nutrition or water, or hospitals, doctors or medicines being available.
Even if there are hospitals or other essential health services, but they are far from the town or area where the child lives, these would not be physically accessible.
Nor would health services and medication be financially accessible if they are too expensive. Due to the absence of health education, families and children living in poverty often avoid spending money on medicines, doctors or sanitary products.
Health care must be acceptable in the sense that it must be provided in an ethical, culturally appropriate, and child-friendly manner.
Lastly, if the health system were available, accessible, and acceptable for street-connected children, but poor in quality, a child would still not be able to enjoy the highest attainable standard of health. Take, for example, the case of a hospital without running water.

As we already explained in our previous note, certain rights can be limited in a state of emergency. Restrictions on rights can never be contrary to the nature of that right. Therefore, in a pandemic, limiting access to health care services related to the pandemic would not be allowed. However, there are examples in countries where access to health services that are considered not urgent have been suspended or limited to allow health workers to focus on care for those ill with COVID-19.

It is important when governments take such measures to limit the right to health, as we’ve seen in previous notes, that these measures are necessary, proportionate, of limited duration, and subject to review. They can therefore not suspend all other health services indefinitely. It is important that governments provide a timeframe during which certain health services may be limited in operation or suspended, and that they review regularly whether these can be reopened.

What legal obligations does my government have to uphold for the right to health during a pandemic?
As with other economic, social and cultural rights, the right to health creates both negative and positive obligations to governments. Under the negative obligations, governments must not engage in, or tolerate, activities of others that deprive or deny children of this right, such as a pharmacist refusing to sell medicines to a street-connected child. As part of the positive obligations, governments must work to make the right to health a reality. In particular, they must work to provide good quality health care, clean water, nutritious food and a clean environment so that every child can stay healthy.

The right to the highest attainable standard of health imposes a series of core obligations that every government must uphold at all times. These include:(xiii)

To provide equal and non-discriminatory access to health facilities, goods and services, especially for vulnerable or marginalised people;
To address health determinants, including:
- To ensure freedom from hunger by providing equal access to sufficient, adequate and safe food; and
- To provide access to adequate housing, sufficient water and sanitation;
To ensure the equal distribution of all health-related resources;
To design and implement timely and effective strategies of prevention, monitoring treatment and control of diseases, giving special attention to the most vulnerable groups. Together with the immunisation of the population against epidemic diseases according to the available technologies, these measures are all a matter of priority.
To provide appropriate training to health workers, including health education and human rights. These measures need also to be prioritised.
Lastly, to provide with urgency health education and access to information to the entire population.

As the first obligation mentions, the government has a core obligation to provide and distribute health care resources equally among the population. Governments must therefore ensure that vulnerable and marginalised individuals are able to access health facilities like anyone else. Vulnerable and marginalised individuals, like street-connected children and homeless youth, often face additional barriers in accessing health services, including health education, as set out earlier in this note. It is important for governments to prioritise these groups to ensure they can enjoy their right to health like anyone else. The UN Committee on Economic, Social and Cultural Rights stressed that governments should pay particular attention to all vulnerable or marginalised in public health strategies and preparing and responding to epidemics, just like the COVID-19 pandemic.

As you can see above, addressing health determinants also falls under the core obligations of the government in realising the right to health. The UN Committee on the Rights of the Child has explained, that as part of this obligation, health determinants such as food, housing and water and sanitation are made accessible to all children and especially to underserved groups in the population,(xiv) such as street-connected children and homeless youth.

The UN Committee on the Rights of the Child has also emphasised that governments must eliminate barriers to access to essential health services that vulnerable children may face, such as the requirement to show proof of identity. It recommends governments to “allow innovative and flexible solutions to avoid the risk that these groups of children are denied access to basic services due to the lack of legal identity.”(xv) Similarly, the United Nations Office of the High Commissioner for Human Rights COVID-19 guidance explained that governments must ensure that no one is denied timely and appropriate healthcare on grounds of their economic, age, or social status.

The obligations of governments extend to health behaviour education and information of children as well. As the UN Committee on the Rights of the Child remarked on different occasions,(xvi,xvii) governments must provide children with information and educational opportunities on health prevention and care which are age-appropriate and take into account the specific needs of different groups of children. These measures are necessary to increase children’s awareness and understanding of health issues to enable them to make informed decisions about the most appropriate behaviour and measures to protect themselves and others.

Finally, it is part of governments’ obligations under the right to health to engage in a recurring process of planning, implementation, monitoring and evaluation of their health policies. Governments should include children throughout this process. Governments have a legal obligation under the child’s right to be heard(xviii) to respect the child’s views on issues that affect his or her health. As the UN Committee on the Rights of the Child specified, the right to be heard applies not only to individual health-care decisions, but also extends to involve children in health policy and services,xix for example, through the setup of feedback mechanisms and consultation processes.

To sum up, the realisation of the right to health during this pandemic requires governments to pay special attention to vulnerable and marginalised groups, such as street-connected children and homeless youth, and remove their barriers to accessing health care to reduce the existing health inequalities in the population. During this time of emergency, governments are therefore urgently called upon to collaborate with NGOs to identify and address the specific needs of street-connected children and homeless youth to ensure that they can enjoy their right to the highest attainable standard of health.

Other papers will be prepared to support CSC’s Network Members and other interested organisations and individuals. Please get in touch with us at advocacy@streetchildren.org to discuss topics relevant to your work on which you would like to see a similar paper. Please do not hesitate to use the above email address if you need individualised support to analyse laws or measures adopted by the Government in your country in relation to responses to COVID-19, which can or already have an impact on street-connected children’s rights.

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i Dong, Yuanyuan, Xi Mo, Yabin Hu, Xin Qi, Fan Jiang, Zhongyi Jiang, and Shilu Tong. 2020. “Epidemiology of COVID-19 Among Children in China.” Pediatrics. https://pubmed.ncbi.nlm.nih.gov/32179660/
ii Kumar, S., and S. C. Quinn. 2011. “Existing Health Inequalities In India: Informing Preparedness Planning For An Influenza Pandemic”. Health Policy And Planning 27 (6): 516-526. https://doi:10.1093/heapol/czr075.
iii Cumber, Samuel Nambile, and Joyce Mahlako Tsoka-Gwegweni. 2015. “The Health Profile of street-connected children in Africa: A Literature Review.” Journal of Public Health in Africa 6 (566): 85– 90. https://doi.org/10.4081/jphia.2015.566.
iv National Institution for Health Care and Guidance. 2020. “COVID-19 rapid guideline: severe asthma.” NICE guideline NG166. https://www.nice.org.uk/guidance/ng166/chapter/1-Communicating-with-patients-andminimising-risk
v Sakai-Bizmark, Rie, Ruey-Kang R. Chang, Laurie A. Mena, Eliza J. Webber, Emily H. Marr, and Kenny Y. Kwong. 2019. “Asthma Hospitalizations Among Homeless Children in New York State.” Pediatrics, 144 (2). https://doi.org/10.1542/peds.2018-2769.
vi Story, Alistair. 2013. “Slopes And Cliffs In Health Inequalities: Comparative Morbidity Of Housed And Homeless People”. The Lancet 382: S93. https://doi:10.1016/s0140-6736(13)62518-0.
vii UNICEF. 2020. “Don’t Let Children Be The Hidden Victims Of COVID-19 Pandemic”. https://www.unicef.org/press-releases/dont-let-children-be-hidden-victims-covid-19-pandemic.
viii https://reliefweb.int/sites/reliefweb.int/files/resources/Malawi-COVID-19-Situation-Update-17.04.20.pdf

ix https://www.gov.uk/government/news/multi-million-support-for-vulnerable-children-during-covid-19
x See Article 25.1 of the Universal Declaration of Human Rights, UN General Assembly, Universal Declaration of Human Rights, 10 December 1948, 217 A (III), available at https://www.refworld.org/docid/3ae6b3712c.html. See also Article 12 of the International Covenant on Economic, Social and Cultural Rights, UN General Assembly, International Covenant on Economic, Social and Cultural Rights, 16 December 1966, United Nations, Treaty Series, vol. 993, p. 3, available at https://www.refworld.org/docid/3ae6b36c0.html. Regional bodies also recognise the right to health. EUROPE: Article 11 of the European Social Charter, Council of Europe, European Social Charter (Revised), 3 May 1996, ETS 163, available at https://www.refworld.org/docid/3ae6b3678.html; Article 35 of the Charter of Fundamental Rights of the European Union, 26 October 2012, 2012/C 326/02, available at https://www.refworld.org/docid/3ae6b3b70.html; AFRICA: Article 16 of the African Charter of Human and Peoples’ Rights, Organization of African Unity (OAU), African Charter on Human and Peoples’ Rights (“Banjul Charter”), 27 June 1981, CAB/LEG/67/3 rev. 5, 21 I.L.M. 58 (1982), available at https://www.refworld.org/docid/3ae6b3630.html; AMERICA: Article 10 of the so-called Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights (Protocol of San Salvador), adopted by the Organization of American States (OAS), 16 November 1999, A-52, available at https://www.refworld.org/docid/3ae6b3b90.html. To date, the Protocol of San Salvador has been ratified only by some member States. Notable cases of non-ratifying States are those of Canada, United States, Colombia and Brazil making considerable exceptions.
xi Article 12 of the International Covenant on Economic, Social and Cultural Rights, UN General Assembly, International Covenant on Economic, Social and Cultural Rights, 16 December 1966, United Nations, Treaty Series, vol. 993, p. 3, available at https://www.refworld.org/docid/3ae6b36c0.html.
xii Article 12 (a) of The International Covenant on the Economic, Social and Cultural Rights (see note 1) explicitly refers to the right of every child to healthy development as one of the key obligations of States parties. The child’s right to health is also specifically recognised by some regional mechanisms. See, for example, Article 14 of the African Charter on the Rights and Welfare of the Child adopted by the Organization of African Unity (OAU), 11 July 1990, CAB/LEG/24.9/49 (1990), available at https://www.refworld.org/docid/3ae6b38c18.html.
xiii UN Committee on Economic, Social and Cultural Rights (CESCR), General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant), (see note xiii above).
xiv UN Committee on the Rights of the Child (CRC), General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), 17 April 2013, CRC/C/GC/15, available at: https://www.refworld.org/docid/51ef9e134.html.
xv UN Committee on the Rights of the Child (CRC), General comment No. 3 (2003): HIV/AIDS and the Rights of the Child, 17 March 2003, CRC/GC/2003/3, available at: https://www.refworld.org/docid/4538834e15.html; UN Committee on the Rights of the Child (CRC), General comment No. 21 (2017): Children in Street Situations, 21 June 2017, CRC/GC/2017/21, available at: https://www.streetchildren.org/resources/general-comment-no-212017-on-children-in-street-situations/
xvi UN Committee on the Rights of the Child (CRC), General comment No. 3 (2003) (see note xv above).
xvii UN Committee on the Rights of the Child (CRC), General comment No. 15 (2013) (see note iv above). UN Committee on the Rights of the Child (CRC), General comment No. 3 (2003) (see note xv above).
xviii Article 12 of the UN Convention on the Rights of the Child.
xix UN Committee on the Rights of the Child, General comment No. 12 (2009): The right of the child to be heard, 1 July 2009, CRC/C/GC/12, available at https://www2.ohchr.org/english/bodies/crc/docs/AdvanceVersions/CRC-CGC-12.pdf