In the context of the VII Conference of the Paediatric Society for Quality and Patient Safety, on 12^th December 2025, I was challenged to reflect on the following question: Can there be quality in healthcare without respect for children’s rights?

When we talk about quality of healthcare, it is imperative to mention children’s right to enjoy the best possible state of health and to benefit from medical and rehabilitation services, Article 24 of the United Nations Convention on the Rights of the Child (UNCRC), also known as the right to health. And, in accordance with human rights’ principles, Article 24 should be understood and applied in relation to the other rights in the Convention. In other words, it is not possible to apply the right to health without applying the child’s right to non-discrimination, the principle of the best interests of the child, the principle of the evolving capacities of the child, and so on. In addition, the Committee on the Rights of the Child, the body that monitors the implementation of the Convention, has been interpreting the articles and providing guidance on how to apply them in various contexts, including the healthcare system. For example, in relation to Article 12, now known as the right to participation, the Committee recognises the right of the child to be informed about their health situation, to participate in decision-making processes, including the right to informed consent, and to participate in the evaluation and improvement of health services (1). Child rights therefore have a practical application within healthcare services.

Returning to the question posed at this round table – can there really be quality in healthcare without respect for children’s rights? – from the end of the 1980s onwards, it became clear in Europe that, despite advances in medicine and improved outcomes in child health, the quality and experience of healthcare varied from child to child. Additionally, with the adoption of the Convention, the growing evidence on the social determinants of health, among other issues, showed that the quality of care is not only related to the application of medical protocols or the effectiveness of treatments. All initiatives created since the late 1980s are based on this assumption. Some of the earliest examples are the adoption of the European Charter for Children in Hospital (2) and the Child-Friendly Healthcare Initiative (3). In one of the first scientific articles published on this approach in 2000, Southall et al. argued that even in rich countries with good resources, “advances in healthcare have not always been accompanied by proportional attention to the general well-being of children and sufficient concern for their anxieties, fears and suffering.” The initiative proposed, “in accordance with the Convention, to develop a system of care that focuses on the physical, psychological and emotional well-being of children who are seen in health facilities, especially during hospitalisation (4).”

This programme was a real cornerstone for subsequent initiatives and laid the foundations for European and international organisations to start talking about a human rights-based approach to health and children’s rights. For example, in 2011, the Council of Europe adopted the Guidelines on Child-Friendly Healthcare and a Ministerial Declaration on the same topic (5); and the World Health Organisation Regional Office for Europe adopted a series of tools and processes for assessing the quality of healthcare, based on children’s rights, from the same period (6).

With this approach, international and national legislation now has a very concrete application in terms of health services. The UNCRC must be transposed into national legislation, public policies, professional training and service organisation, with a view to continuous improvement, in accordance with the situation of children. And, in terms of services, this approach is based on seven principles, namely:

1. Availability of health services, including organisation, availability of various types of necessary services and their geographical distribution;
2. Access to healthcare, i.e. physical and economic access to healthcare without constraints, as well as access to information;
3. Acceptability of healthcare, i.e. the healthcare services available must be accepted by all population groups, regardless of their characteristics and with respect for their specific needs;
4. Quality of services in terms of their effectiveness, taking into account the needs of the population and based on clinical protocols and scientific evidence;
5. Participation, i.e. children have the right to participate in healthcare at an individual level, for example in decisions about their care (assent and informed consent), and at a group level, i.e. in the design, planning and evaluation of existing services;
6. Equality and non-discrimination, i.e. everyone has the right to enjoy care without discrimination of any kind, in accordance with the above principles;
7. Accountability at the level of the health system, in the form of accreditation, monitoring and evaluation systems, but also in terms of compensation (7).

As mentioned above, from the late 1980s onwards, with an acceleration in the 2000s, several initiatives were promoted to improve the quality of healthcare based on children’s rights, but global standards had yet to be adopted. In 2018, based on the experiences gained up to that point, particularly in terms of assessing the quality of paediatric healthcare, the World Health Organisation adopted standards for the quality of child healthcare, which include quality from the perspective of clinical effectiveness and respect, protection and fulfilment of children’s rights (8). According to the document, in order to ensure the quality of healthcare, the following rights, among others, must be guaranteed:

1. Effective communication with children and families, including participation in decision-making processes, which presupposes the availability of information in different formats, the adoption and dissemination of a charter of rights and internal policies on informed consent and assent;
2. Access to services without discrimination;
3. Protection from all forms of violence;
4. Recognition of the role and exercise of parental rights;
5. The right to education and play.

The question of whether quality healthcare can exist without fulfilling children’s rights is simple. Experience shows us that children’s rights are an integral part of quality. This is not to say that we have achieved an adequate state of protection and care for all children. On the contrary, we are still faced with having to justify and fight for children’s rights to receive the attention and merit they deserve, for example, in terms of accreditation systems; and, on the other hand, with the lack of investment in this area and the new challenges that have always accompanied paediatrics, how will we ensure to make it possible to continue the advances in the humanisation of care and the fulfilment of children’s rights that have been achieved so far.

(1) United Nations Committee on the Rights of the Child. (2009). General Comment No. 12 (2009) The right of the child to be heard, CRC/C/GC/12. United Nations. https://digitallibrary.un.org/record/671444?ln1⁄4en

(2) European Association for Children in Hospital. EACH Charter

(3) Nicholson S and Clarke A (2005) Child friendly healthcare. A manual for health workers, web published by Maternal Childhealth Advocacy International

(4) Southall et al. The Child-Friendly Healthcare Initiative (CFHI): Healthcare Provision in Accordance with the United Nations Convention on the Rights of the Child. PEDIATRICS. Vol. 106. N. 5. November 2000

(5) Council of Europe (2011) Child-Friendly Healthcare. 

(6) Guerreiro et al. Assessment and improvement of children’s rights in health care: piloting training and tools in Uzbekistan. Public Health Panorama. Volume 1 (3) December 2015, 205–268

(7) Maria do Céu Machado, Ana Isabel F. Guerreiro e Sónia Borges Rodrigues (editoras). Os Direitos da Criança em Contextos de Saúde. Publicações Almedina. 2024

(8) WHO (2018) Standards for improving the quality of care for children and young adolescents in health facilities. Geneva: World Health Organization. Licence: CCBY-NC-SA3.0IGO