CB Chow

In the 60s, Hong Kong was called City of Children where over 43% of population were under 16 years of age. In 1980, around 27% of population were under 15 years of age. At present in Hong Kong there are more than 1.3 million of children aged under 18 years of age accounting for around 20% of the total local population. The vital statistics of children has improved dramatically over the past three decades and the infant mortality of 1.8 per 1000 live births ranks second in the world in 2006.

In 1979, in contribution to the International Year of the Child, a Hong Kong International Years of the Child (IYC) Commission was formed with representatives from welfare, medical, educational, social, legal and Christian bodies and produced a comprehensive evaluation report on "The Child in Hong Kong".¹ It was very disappointing however, that Hong Kong Government had not officially proclaimed 1979 as the International Year of the Child nor adopted the recommendation from the IYC Commission in developing a child policy and the setting up a Child Commission. Convention on the Rights of the Child (UNCRC) was endorsed by United Nation in 1989. At present all countries have ratified the Convention except for the United States and Somalia. In 1994, British Government ratified the UNCRC on Hong Kong's behalf with two reservations. After ratification of the Convention, Hong Kong should be obliged to fully implement the articles in the Convention and make progress report to United Nation Committee on the Rights of the Child (UNCCR) every five years. The first report was submitted to UNCCR in 1996. In the concluding observation, Hong Kong was recommended to establish an independent mechanism specifically to monitor the implementation of government polices on UNCRC. A second comprehensive report "Hong Kong's Children : Our past, their future" was published in 1999 by Centre of Asian Studies, again concluded the need of a comprehensive child policy and child commission in Hong Kong.² A third Hong Kong report was submitted to UN Committee on Children's Rights in 2005 and again the Hong Kong Government still considered that "existing arrangements were effective, enabling us to make flexible and quick responses to address concerns of the public on children." Again, UNCRC in the concluding observation recommended that Hong Kong should establish an independent child commission to implement and monitor the implementation of UNCCR. Also despite repeated calls from scholars and professionals, rights of the child as an individual have never been given proper recognition by the Government and despite ratification, the Convention on the Rights of the Child has never been duly implemented in Hong Kong. In 2006, an Alliance on Children's Commission was formed composing of 23 NGOs including the Hong College of Paediatricians and Hong Kong Paediatric Society to advocate, reason, persuade, lobby if not pressurise the Hong Kong Government in the setting up of a Children Commission to safeguard and promote the rights and well-being our children, our future. With the help of two legislators, a motion was moved and passed on 8 June 2007 in the Legislative Council "That this Council urges the Government to set up a Commission on Children to fulfill the obligations under the United Nations Convention on the Rights of the Child, safeguard the well-being of children, and ensure that children's perspectives are fully taken into account in the process of formulating government policies." However, up till the present, we still do not have an over-arching child policy, nor a comprehensive children's act. Children's views are still not solicited for policy and service development, and a child commission is not considered necessary by the Government. Instead a Family Council was formed by the Hong Kong Government in December 2007 with a term of reference of:

a. to advocate for cherishing the family as a main driver for social harmony; and to promote a family-based support network to forge closer and harmonious relationships amongst family members;

b. to advise the Government on the formulation of policies and strategies for supporting and strengthening the family and on development of related programmes/activities and to monitor their implementation;

c. to advise the Government on the integration of family policies and related programmes across different bureaux and departments for individual age and gender sectors to ensure effective coordination;

d. to plan/implement programmes and activities for particular age and/or gender sectors; and rationalise the work of the Elderly Commission, the Women's Commission and the Commission on Youth;

e. to initiate research to promote better understanding of matters related to the family as necessary.

Children again were not included in the term of reference as there is no children's commission but Hong Kong has established a Youth Commission in 1990, Elderly Commission in 1997 and Women's Commission in 2001. After a year's deliberation by the Family Council, we are still awaiting her first report or policy statement.

The article by Professor Sheila Kamerman is timely.³ It has highlighted several important points. Firstly, "family policy is what government does to and for children and their families and characteristics of family policy internationally is concern for all children and their families, not just poor families and families with problems". Hence the term of reference for our Family Council is at odds with international practices - children are totally ignored. Secondly, "family is recognised as an essential institution in society fulfilling an essential societal role in reproduction, in socialisation, in early education, in the promotion of health, in preparing the next generation for adulthood". It is well acknowledged that better performance by children requires help for parents and the family unit as well. However, families are now changing rapidly in composition, in structure and in functionality. Also these changes do occur over the life course of a child producing great impacts. While we are addressing family policies to make a difference, we will need to specially focus on the most vulnerable group - the children. Hence having special representations on children in the Family Council and the need for setting up of a Child Commission will be blatantly obvious. Thirdly, most if not all Central and Eastern European countries with explicit family policies are child-focused. The Sweden and France Family Policies were developed from protection of children or to compensate families for the economic costs of child rearing. Several family policy developments and innovations especially on "child-conditioned social protection" were described in the paper like asset-based policies and child development account, child trust funds, conditional cash transfers, early childhood education and care services. While our Government has repeatedly claimed that social protection for children in Hong Kong has been adequate but the main income transfer programme is a low level cash assistance benefit for the poor with a limited capacity to work or benefit for traditional social risks of old age, disability and sickness. These measures are inadequate for the protection of children from low income families. The recently introduced programmes like the Comprehensive Child Development Service in 2007, Child Development Fund in 2008 and voucher system for pre-school education were implemented in a fragmentary manner and not as a coherent package. There has been no central policy for coordination and evaluation to obtain solid data to support the effectiveness of these policies. Many experts have cast doubt on their effectiveness.

The conclusions in the article by Professor Kamerman are very valid: (1) Although Hong Kong appears to have a number of other family initiatives, it is difficult to obtain a coherent picture of what is provided with what consequences. The family friendly policies are linked with employers rather than a wider family policy framework like "Babies and Bosses". (2) "What appears to be missing from family agenda (in Hong Kong), however are child benefits". (3) The biggest gap is the lack of a coherent, holistic and comprehensive picture of the situation of children, the policies to respond and an assessment of what works. Not only is there no "State of the Child Report in Hong Kong", and worse still, in the Population Census conducted in 2001 and bi-census in 2006, there were Theme reports on Women, Youth, Elderly but not on Children! (4) Finally, a holistic approach to the development of a coherent policy agenda on child and family well-being remains to be established but making the conditions of children and families more visible, and assessing the policies affecting them would be vital if we are to improve the conditions of children and their families. Children are "invisible" in many areas of Hong Kong policies. As a result, children and their experiences remain hidden and only rarely are they informed or consulted during the process of decision making which may have far reaching implications.

While the Hong Kong Government always claims that the health status of our children remains one of the best in the world (Infant mortality was only 1.8 in 2006), yet we are seeing a rapidly deteriorating physical and socio-economic environment for our children and hence also their health status :

• About 26.5% of children (247800) aged 0-4 are living in households with income below average CSSA payment in 2006.⁴

• Divorce rate has doubled in last decade and about a third of the marriages end in divorce and single parents have doubled in past decade from 42309 in 1996 to 72326 in 2006.⁵

• About a third of children had ever experienced physical maltreatment and domestic violence had been reported in about 14% of families. The prevalence of psychological abuse or neglect was even higher (2005).⁶

• The physical environment especially air pollution and space for recreational activities has also deteriorated rapidly.

• We are seeing an increasing obesity rate to 18.7% among primary school children reported in 2003/2004 as a result of inactivity, over-nutrition and prolonged TV viewing or indulgence in video games.

• The reported number of young drug abusers aged under 20 years has increased by 34% in the three years ending 2007.⁷

• Our children belong to the most unhappy group in Asia. A study conducted by the Centre for Suicide Research and Prevention at the University of Hong Kong in 2005 showed that 28 to 42 per cent of secondary school students had considered committing suicide.

• While Hong Kong students still ranked in the top three on mathematics and science in TIMMS and PISA in 2007, but they were generally much lower than the international averages on their higher values, higher positive affect and self-confidence in learning mathematics and science.⁸

The list can go on and it becomes clear that the health status of our children is at stake. One can ask whether a Child Commission really works? Majority of the ills in our adolescents and young adults results from adverse experiences in childhood. We need to focus on children now in order to prevent ill effects in youths and adults. It has been found that many polices by focussing solely on the circumstances of families, households or women, children's experiences or opinions are overlooked or rendered "invisible" to the detriment of their welfare especially when it comes to divorce and custody issues. Studies on effectiveness of Children's Commission are few but there is enough evidence to show that it will help overall coordination and accountability, support for policy development and implementation, monitoring of results and promotion of greater visibility on policy on children and their rights. Evidence and experience from many countries also support the dire need to set up a child-focused organisation to speak, plan and monitor on the best interest of children. The Connecticut Commission on Children estimated that the cost of $1.30 per child invested in the State Commission on Children produced a triple return at the state and local level from enhanced policy development and implementation, extensive public information and capacity building.⁹

It is now well established that the health of children is a product of complex, dynamic, accumulative (longitudinal) interactions of external influences, such as children's family, social and physical environment (multidimensional) and their genes, biology and behaviour. Children's health is greatly affected by a wide range of social determinants. A narrow disease or social welfare focus will not address all the issues faced by our children. A divided accountability and responsibility is the greatest barrier to effective children's services addressing these adverse factors. We need a common and shared understanding of the genetic-socio-ecological-developmental approach for policy and strategy development, service implementation and monitoring. We need a Children's Commission to champion this, motivating policy and system change.

It is false economy not to invest in children. A child policy and a child commission is not necessarily about spending more money, but rather it is about ensuring the best use of existing resources through better policy formulation, improved service coordination, striking a balance between health promotion, early intervention and remedial services. At present over 50 countries have established either child commission or child ombusman and more are focusing on early child development.

As rightly pointed out by a famous economist James Heckman :

"An important lesson to draw from the entire literature on successful early interventions is that it is the social skills and motivation of the child that are more easily altered-not IQ. These social and emotional skills affect performance in school and in the workplace. We too often have a bias toward believing that only cognitive skills are of fundamental importance to success in life. The later in life we attempt to repair early deficits, the costlier the remediation becomes."

"The real question is how to use the available funds wisely. The best evidence supports the policy prescription: Invest in the Very Young."

Finally what are the roles of the paediatric and child health professionals with respect to UNCRC? The American Academy of Pediatrics (AAP) endorsed the UNCRC in 1989 and used it as framework for provision of health care services to children. A training module has also been developed to educate residents on the Convention emphasizing that the articles of the Convention on the Rights of the Child characterise the fundamental prerequisites for child health, paediatrics in general and community paediatrics. Community paediatricians in particular must expand their professional skills to engage in advocacy, policy development and social science research as essential elements of the practice of paediatrics. AAP has also petition to Congress for ratification of UNCRC.¹⁰

The Royal College of Paediatics and Child Health (RCPCH) has adopted an overall aim: "To advocate the rights of children and young people in society and to promote their health needs and services", promoting implementation of the UN Convention on the Rights of the Child throughout the College and in all areas of society and institutions. The RCPCH expects all members to act within the framework of this Convention when undertaking any form of advocacy for children.¹¹ Trainees are expected to read in addition to Good Medical Practice (2001) and to Good Medical Practice in Paediatrics and Child Health (2002), also the Laming Report⁴ (2003) and the UN Convention on the Rights of the Child.¹² Paediatricians should commit themselves to practise in accordance with the Objects of the College and the UN Convention on the Rights of the Child. Our College should also endorse UNCRC officially, include the UNCRC in the training curriculum and be a strong advocate for the full implementation of UNCRC in Hong Kong for the benefit of our children.

References

1. Evaluation Report - The Child in Hong Kong. Hong Kong: Hong Kong International Year of the Child Commission, 1980.

2. Pryde NA, Tsoi MM, editors. Hong Kong's Children: Our past their future. Hong Kong: Centre of Asian Studies, The University of Hong Kong, 1999.

3. Kamerman SB. Families and Family Policies: developing a holistic policy agenda. HK J Paediatr (new series) 2009: 115-21.

4. Report of Commission on Poverty. Hong Kong: Commission on Poverty, The Government of the Hong Kong Special Administrative Region, 2008.

5. Thematic report on single parents. Hong Kong: Census and Statistical Department, February 2008.

6. Study on child abuse and spouse battering. Overall report (Part one). Hong Kong: Department of Social Work and Social Administration, The University of Hong Kong, 2005.

7. Report of the Task Force on Youth Drug Abuse. Hong Kong: The Government of the Hong Kong Special Administrative Region, 2008.

8. Trends in International Mathematics and Science(TIMSS). Hong Kong: Faculty of Education, The University of Hong Kong, 2007.

9. The commission on children at the cutting edge. US: State of Connecticut General Assembly, Commission on Children, February 2009.

10. U.S. Senate Staff Briefing on the UN Convention On The Rights of The Child presented by Jennifer Kasper, on behalf of the American Academy of Pediatrics, November 20, 2008.

11. Advocating for Children. UK: Advocacy Commission, Royal College of Paediatrics and Child Health, 2008.

12. Good Medical Practices in Paediatrics and Child Health - Duties and Responsibilities of Paediatricians. UK: Royal College of Paediatrics and Child Health, 2002.