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Global Child Survival: A Human Rights Priority

Executive Summary

We are guilty of many errors and many faults, but our worst crime is abandoning the children, neglecting the fountain of life. Many of the things we need can wait. The Child cannot. Right now is the time his bones are being formed, his blood is being made and his senses being developed. To him we cannot answer "Tomorrow." His name is "Today."

–Gabriela Mistral, Chilean Poet and Nobel Laureate

Summary and background

More than 12 million children under the age of five still die needlessly each year from "diseases of poverty," including immunizable childhood diseases, malaria, intestinal and respiratory infections, lack of food and clean water, violence, and lack of primary health care. These avoidable child deaths are unconscionable at a time when preventative and curative measures are available and remarkably cost-effective. Advances in child survival have reached only a portion of children around the world. Even within industrialized nations, significant disparities in infant and child mortality persist.

The continuing worldwide crisis of excessive child mortality is not only a tragedy, it is a human rights violation. Recent global efforts to reduce child mortality reflect both remarkable successes and dismal failures. Although dramatic improvements in child survival have occurred in the past 50 years, many innocent children are still denied the chance to live to see their fifth birthday. Without their most fundamental human right—the right to survive—no other human rights have meaning. The Convention on the Rights of the Child is the most widely ratified international human rights treaty in history. It recognizes the child's inherent right to life and articulates the obligation of governments to "ensure to the maximum extent possible the survival and development of the child." This obligation includes a guarantee to "a standard of living adequate for the child's physical, mental, spiritual, moral, and social development" regardless of the child’s gender, race, or socioeconomic status. The Convention represents the minimum standards for children’s rights. The failure of ratifying governments to provide all their infants and children conditions adequate for survival and healthy development violates these minimum standards.

This report outlines the interdependence between health and human rights. It analyzes the international standards that are breached by avoidable child deaths and defines the responsibilities of governments to protect the fundamental human rights of their children. A commitment to the protection of these rights by governments and the international community is critical to ensure that every child has an equal chance to live and develop.

High rates of child mortality worldwide are caused by the combined effects of biological, behavioral, and socioeconomic factors. The immediate cause of a child’s death is usually a biological event such as an infection. A behavioral factor on the part of the parent or care provider, such as delay in seeking health care for the child, may also contribute to the death. Most child deaths are accompanied by underlying structural or socioeconomic factors. In many cases, impoverishment, lack of basic necessities, prohibitive costs of health care, lack of social services, and the inferior status of women in a society all contribute to high levels of child mortality. An understanding of the interconnection of these causes is essential to the development of effective strategies to increase child survival.

This report describes the specific obligations under international human rights law for the protection of child survival and health. While sustainable social and economic development is indispensable to child survival, it may also prevent other human tragedies. A respect for the full range of human rights protected under international law will improve child survival and provide a clear mechanism to determine policy and programmatic priorities. In addition to increased child survival, a respect for human rights will improve the health and livelihood of women and enhance socioeconomic conditions for the entire population.

This report uses a case study approach to analyze the child survival situation in three countries of varying levels of development—Uganda, Mexico, and the United States. The report also sets forth the relevant obligations under international human rights law and makes recommendations for measures to increase child survival and health.

Findings of this report

Global child survival has improved since the 1950s but the benefits reach only a portion of the world’s children. Children in developing countries are more likely to die before reaching age five than children in developed countries. Uganda’s children under age five face a child mortality rate that is one of the world’s worst at 147 deaths per 1000 live births. In Mexico, mortality rates of children under five have fallen considerably; however, these rates are still disproportionately high for its development level and comparatively higher than those of other middle income countries. In the United States, the overall rate of infant mortality ranks worse than 20 other developed countries. The death rate among U.S. Black infants is even higher than those of developing countries such as Costa Rica, Cuba, and Sri Lanka.

In both developing and developed countries, poor people, racial and ethnic minorities, and indigenous groups have disproportionately higher rates of child mortality. In Uganda, over 60 percent of the total population live in poverty and 90 percent of the people reside in rural areas. Across the country, one in six Ugandan children dies before reaching age five. In Mexico, the situation is equally compelling. Mexican children from poor and rural areas, where the incidence of poverty among indigenous populations exceeds 80 percent, are most susceptible to preventable deaths. The U.S. case example reveals that gross disparities in infant and child mortality rates persist among different population groups in the country. Poor children and Black children are the most vulnerable in the United States. Black infants die at more than twice the rate of White infants. The mortality rate among U.S. infants from poor families is 60 percent higher than for infants above the poverty level.

Data on issues critical to child mortality are inadequate and are not disaggregated in a manner useful to developing effective policies and programs. In many countries, data are kept on the overall rate of child mortality while data on the specific circumstances of individual deaths or the regions where the deaths occur are not adequately recorded. Overall child mortality rates mask important variations among population groups within a country. In Mexico, data on child mortality collected by the government are unreliable. First, the information varies widely by sources within the country and is inconsistent with data collected by UNICEF. Second, government data on child mortality are lacking for regions where large numbers of indigenous people live. Similarly, in the United States significant discrepancies exist in the collection of data useful for understanding and preventing the underlying causes of disparities in infant mortality. For example, although vital records of births and deaths are the primary data sources for understanding patterns of infant mortality in the United States, information about the household income status of infants at the time of their birth or death is not included in these records.

Children under age five are dying primarily from preventable causes that include biological, behavioral, and socioeconomic determinants. In developing countries, child deaths are caused largely by the "diseases of poverty" such as immunizable childhood diseases and malnutrition. The low socioeconomic status of mothers, unsafe water, lack of nutritious food, and punitive government policies also contribute to excessive child deaths. In industrialized countries, children often die from low birth weight and preterm births, abuse and neglect, and accidental injuries. As in non-industrialized countries, socioeconomic factors impact child survival in industrialized countries.

Structural factors which contribute to child mortality include absolute poverty, lack of basic necessities, discrimination, unbalanced macroeconomic policies, and unsustainable external debts. Resource disparities among population groups generally parallel the disparities in child death rates in these groups. The Uganda case study illustrates the formidable constraints to improving child survival and health in a developing country. Uganda is one of the poorest and most heavily indebted countries in the world. Child and maternal mortality rates are among the world’s highest, while access to essential health care and safe water lags far behind. The low social status and high illiteracy of women in Uganda undermine the health of children as well as women.

In Mexico, persistent socioeconomic inequities are exacerbated by economic and structural adjustment policies. Government economic policies have been biased toward urban centers at the expense of marginalized areas. In the past decade, the Mexican government has systematically pursued austerity and structural adjustment programs in accordance with World Bank and IMF specifications. This process has aggravated inequities in socioeconomic development between urban and rural areas. The Mexican government has treated issues such as poverty and disparities in child mortality rates as acceptable consequences of the country’s economic development, rather than violations of economic, social, and cultural rights. As a result, child mortality is viewed as inevitable rather than preventable.

The United States has seen dramatic changes in public benefits for health care and social welfare since the 1980s. U.S. strategies for reducing infant mortality have had mixed success in the last two decades. "Reforms" in the social and health delivery systems, if not carefully scrutinized, may undermine the improvements that have been made and increase infant and child health differentials between socioeconomic classes. This pattern is especially troubling in light of the projected increase in the percentage of disadvantaged children in the United States. The child poverty rate has already grown to nearly 22 percent and is now the highest in the industrialized world.

Ameliorative measures are available and affordable. A global strategy to promote "Health for All by the Year 2000," which was proposed at the 1978 Alma-Ata International Conference on Primary Health Care and adopted by the World Health Assembly in 1981, provides a practical framework for improving child health and survival worldwide. The 20:20 initiative suggests a strategy through which aid donors and governments can earmark 20 percent of their budgets towards meeting the social goal of universal access to primary health care and nutrition, reproductive health, water and sanitation, primary education, and other basic social services. U.N. agencies as UNICEF, UNFPA, WHO, UNDP, and UNESCO endorsed the 20:20 initiative in 1994. In spite of these global strategies, basic child survival strategies in Uganda remain under-funded. The government dedicates greater resources to defense spending, the debt burden, and low-impact, tertiary health care. Uganda has not succeeded in carrying out its plans to improve child survival by moving resources away from curative, hospital-based programs to primary and preventative health care.

The Mexican government’s response to preventable child mortality in marginalized areas remains inadequate. While Mexico’s domestic laws, institutions, and administrative programs appear consistent with the Alma-Ata primary health care approach, they do not support long-term solutions to the problem of preventable child mortality. Rather, government programs to reduce child mortality are framed in terms of short-term poverty alleviation or social assistance. Health and social programs are often politicized and do not adequately address the disparity in child survival nor the underlying socioeconomic conditions which threaten the health and survival of children.

In 1990, the United States government adopted its own national initiative called Healthy People 2000 which sets specific objectives for achieving health for all U.S. residents by the year 2000. Healthy People 2000 emphasizes the reduction of persistent disparities in health between certain groups who bear the disproportionate burdens of poor health and the population at large. The country’s gross disparities in infant mortality are associated with the racial and ethnic background as well as the gender and socioeconomic status of various population groups. Although overall health has improved, health conditions for some disadvantaged groups have deteriorated. The status of Black infants as compared to White infants is an apt illustration. Use of prenatal care has improved for both Blacks and Whites, but remains significantly higher for Whites. The incidence of low birth weight remains stable for Whites and has increased for Blacks. The disparity in Black and White infant deaths rates is growing. It now appears unlikely that the main objective in reducing racial disparities in U.S. infant health can be achieved by the target year.

Disparate levels of avoidable child deaths reflect a failure on the part of governments to respect and ensure the basic guarantees essential to child survival. Child survival is a predicate to the enjoyment of all other human rights. Of the three countries studied in this report, only the United States has not ratified the Convention on the Rights of the Child. The United States has, however, ratified the International Covenant on Civil and Political Rights and the Convention on the Elimination of Racial Discrimination, which require the government to protect its children against racial discrimination in health and development. The widening disparity in infant mortality and in the socioeconomic status of its citizens points to a general failure on the part of the U.S. government to meet international standards to protect and provide for the human rights of all its children.

Although the Mexican government has ratified and adopted international instruments relevant to child health and survival, Mexico has not effectively complied with its international obligations to protect the basic guarantees to life, health, and non-discrimination. Despite domestic laws and programs related to health, Mexico has not adequately protected the health and survival rights of poor, rural, or indigenous children. Increasing socioeconomic and child survival disparities in marginalized communities constitute discrimination, violating international law.

Uganda’s domestic law places a priority on child welfare, however, legal and resource limitations hinder the protection of children’s rights. The 1995 Constitution of Uganda recognizes and protects the right to life, but contains no explicit guarantee of the right to health. In addition, the enforcement provisions of the Constitution do not apply to the right to health. The Children’s Statute of 1996 specifies children's rights and places shared responsibility for ensuring those rights on the nation, parents, extended families, and local authorities. In practice the country faces the enormous challenge of marshaling adequate human and financial resources to implement these guarantees.

General recommendations

To governments

Take all necessary steps to assure basic and fundamental human rights, including:

Fully comply with human rights treaties and instruments, in particular, the Convention on the Rights of the Child.

Observe the Alma-Ata principles of primary health care by ensuring equity, universality, community participation, and intersectoral collaboration in health policies and programs. All segments of the population must be enabled to define and guide their own well-being.

Adopt a cohesive strategy for child survival that promotes long-term investments and solutions, and de-emphasizes short-term measures. In particular:

operate child survival programs that include:

·         universal immunization

·         oral rehydration therapy

·         micronutrient supplemental and nutrition programs

·         breast-feeding promotion

·         reproductive health and family planning services

·         epidemic control and prevention;

improve environmental conditions such as access to good sanitation and safe water, instead of reliance on oral rehydration therapy alone;

enact equitable food policies (e.g., equitable distribution of income and food sources, famine prevention, targeted food supplementation, and stabilization of food prices), rather than targeted micronutrient/food supplementation alone;

monitor and evaluate the status of children through a permanent system for periodic collection of reliable disaggregated data; and,

fund on-going research on children’s issues to shape policies and programs.

Take legal and policy measures to ensure that the status and role of women will improve the quality of their life as well as the health and welfare of their children and family. In particular:

take all necessary steps to fully comply with the Convention on the Elimination of All Forms of Discrimination Against Women;

guarantee by law and practice that all women have universal access to health and education, economic opportunity, and improved standards of living;

provide resources to ensure equality in gender relations within the family structure and the larger society.

Accede to the United Nations’ 20:20 initiative that calls for a prioritized resource allocation towards basic health and social development: a minimum allocation of 20 percent of governmental budgets and 20 percent of donor countries’ official development assistance.

Comply with obligations under international human rights law to assist poorer countries in realizing the rights essential to the survival and health of children.

Develop an organized public education and advocacy program to heighten awareness of the need to improve maternal and infant health that should be directed toward the general public, women of childbearing age, families, teachers, and employers.

To international financial institutions

Ensure that finance and economic development programs do not disadvantage poor, rural, and agrarian regions by focusing only on urban centers and the global market.

Continue the joint initiative of debt relief and poverty reduction in development policy and program planning. A more progressive debt reduction plan must be considered for all poor countries, particularly indebted countries that have a demonstrated commitment to the social sector, institutional and human capacity building, poverty alleviation, and development of a democratic and civil society.

Apply a social conditionality on future loans as a strategy to compel loan-recipient countries to mobilize greater national resources specifically for health and social development.

To U.N. specialized agencies and international health/development non-governmental organizations

Emphasize ratification and observance of human rights treaties, especially those which guarantee rights related to child health and survival, including:

Continue active involvement in the monitoring of global child survival and health. Facilitate the work of the Convention on the Rights of the Child, the International Covenant on Economic, Social and Cultural Rights, and the Convention on the Elimination of All Forms of Discrimination Against Women. Improve the selection and collection of appropriate (disaggregated) social and health indicators to measure more accurately the impacts of policies and programs.

Facilitate and improve the linkages between U.N. specialized agencies, international health and development (non-governmental) organizations, governments, and international financial institutions to improve child survival through national planning and implementation.

Promote primary health care objectives that are low-cost, high-impact, and appropriate to local situations.

Support long-term, grass-roots development that improves social conditions and human capacity in a sustainable manner.

Country-specific recommendations


Comply with all human rights obligations under treaties and instruments to which Uganda is a party.

Promote and protect children’s rights, in particular those related to child health and survival, through adequate programs and funding.

Continue legislative efforts as well as target social spending to promote the rights and status of women. Government funds should support the implementation of a massive women’s literacy campaign.

Repeal or update provisions of the Public Health Law that are inconsistent with the Local Governments Act. Increase the resources available to the Ministry of Health and Local Councils to guarantee the implementation of reasonable minimum health standards regardless of the wealth of the various districts. The cost sharing scheme for the health sector should be re-examined and modified to ensure accessibility to the poor.

Provide funds to support high-impact primary health care strategies as a national priority, including the required human capacity resources outlined in the Uganda National Plan of Action for Children reform program. Funds made available from the current IMF and World Bank debt relief initiative provide an excellent opportunity to invest in the Uganda National Plan of Action for Children primary health care package.

Use debt relief funds effectively and sustainably to increase child survival. After demonstrating the impact of debt relief on child survival, more IMF and World Bank debt should be forgiven.

Target rural communities in the provision of health and social service funds.


Comply with all human rights obligations under treaties and instruments to which Mexico is a party.

Promote and protect children’s rights, in particular rights related to child health and survival, through adequate programs and funding.

Combat preventable childhood deaths and diseases among all segments of the population as a national health priority to which the maximum available resources must be allocated.

Adopt a cohesive strategy for child health and survival which promotes long-term investments and solutions to alleviate underlying socioeconomic disparities in marginalized areas, including:

poverty: reorient socioeconomic development policies to redress the devastating impacts in rural and poor communities resulting from World Bank/IMF austerity programs, and government biases and "reforms";

malnutrition: establish equitable food policies which promote self-sufficiency through food production and livable wages rather than dependency on micronutrient/food supplementation subsidies;

lack of clean water, basic sanitation, and safe housing: improve environmental conditions to prevent childhood diseases resulting from unsafe housing and water, and lack of basic sanitation systems; and

lack of health and social services: ensure affordable, accessible, and quality health and social services, especially for women and children, which take into account the socioeconomic and cultural concerns of marginalized, particularly indigenous, populations.

Observe the Alma-Ata principles of primary health care by ensuring equity, universality, community participation, and intersectoral collaboration in health policies and programs. All segments of the population must be enabled to define and guide their own well-being.

Improve the productive life and health of women, particularly rural women, as well as the welfare of their children and families.

Target resources to poor and rural communities, and implement urgent measures to ensure balanced and equitable economic growth in both urban and rural areas.

Correct inconsistencies in child health data, with particular attention to issues of validity and reliability, and utilize disaggregated indicators for vulnerable populations.

Consult nongovernmental organizations and consider their information and recommendations in health policies and programs.

United States of America

Ratify the Convention on the Rights of the Child, the International Covenant of Economic, Social and Cultural Rights, and the Convention on the Elimination of All Forms of Discrimination Against Women.

Ensure implementation and compliance with all human rights obligations under treaties and instruments to which the U.S. is a party.

Promote and protect children’s rights, in particular rights related to child health and survival, through adequate programs and funding.

Achieve further reductions in the disparity in infant mortality and morbidity. Such reductions require changes in social and economic barriers to healthy pregnancy and birth outcome. Both the public and private sectors should increase their investment in health care coverage, child care, education, and training.

Ensure that the changes in public benefits and health-care delivery do not further threaten child health and survival.

Implement strategies that minimize the risks of unintentional injuries and violence toward children. Prevention of child abuse and neglect should focus on the millions of high-risk families who are living below the poverty line or are plagued by domestic violence and substance abuse—major risk factors for child ill-treatment.

Adopt an integrated policy on children’s health and well-being in both the federal and state governments, addressing not only the medical needs of all expectant mothers and newborns, but also investing in broad-based preventive approaches.

Strengthen coordination between state and federal programs and social and health services for women and their children. A comprehensive service delivery system is needed, offering perinatal clinical services and linkages between community-based health care and social services.

Increase funding at the state and federal level for monitoring, data collection, and research on the status of children’s health and well-being.

The Child Survival Project of Minnesota Advocates for Human Rights invites and encourages comment on this report, which is part of an overall strategy to build support for promoting economic, social and cultural rights. This report is intended to serve as a catalyst for future research and advocacy.

Over the next two years, the Child Survival Project will bring together a coalition of new constituents and resources for promoting child survival through public education and advocacy. The Project will assist human rights and health advocates, educators, lawyers, parents, health and development professionals, and policy makers, to work collaboratively to protect the basic rights of vulnerable children and to lower the rates of child mortality. The process of implementing human rights guarantees invokes mechanisms that can promote child survival. At national and local levels, laws, policies, and programs can be assessed in light of a government’s international human rights obligations. At the international level, advocates can use international and regional bodies, such as the Committee on the Rights of the Child and UNICEF, to present information about a country’s compliance with its obligations under international law and advocate for corresponding international assistance and pressure.

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