以「兒童蓬勃指數」評估臺灣兒童健康福祉

Abstract

背景：聯合國於1989年通過《兒童權利公約》，其中第24條所規範的「兒童健康權」，除了要求締約國須提供必要的醫療及健康照顧，更應考慮社會、環境等健康決定因素。臺灣也在2014年實施了《兒童權利公約施行法》，但國內少有研究討論該公約與兒童健康福祉之關聯。世界衛生組織、聯合國兒童基金會及「柳葉刀」共同發展了「兒童蓬勃指數」(Child Flourishing Index, CFI)，其以聯合國永續發展目標(SDGs)為主幹，並納入兒童權利、環境永續、公平等多面向，評估兒童之健康福祉。因此，本研究之目的在建置臺灣「兒童蓬勃指數」，並進行跨國及跨年度分析，以了解臺灣兒童健康福祉在該施行法後之狀況。 方法：本研究採用比較分析法及次級資料分析法，透過美國西雅圖華盛頓大學的健康數據評估中心(IHME)資料庫，以及我國公務統計所對應之指標，計算臺灣「兒童蓬勃指數」，接著與南韓、日本、新加坡等國比較，並進行2014年、2017年、2020年各項指標跨年度分析。 結果：「兒童蓬勃指數」指標包含生存維度、茁壯維度、二氧化碳超量排放及吉尼係數等指標，研究結果如下：(1)臺灣2017年「兒童蓬勃指數」總分為0.9分，在全球180國中，我國總分排名在前24名，生存維度排名在前34名，茁壯維度則與其他7國並列第1名。(2)跨國比較：臺灣「兒童蓬勃指數」總分0.9分，落後於南韓、日本、新加坡；我國生存維度的「孕產婦死亡率」、「0-19歲道路傷害死亡率」，以及茁壯維度的「低出生體重率」、「5歲以下兒童發展遲緩盛行率」及「18-29歲民眾在18歲以前受過性別暴力的比例」待改善。(3)跨年度比較：比較2014年、2017年、2020年之各項指標，我國在「15-24歲自殺死亡率」及「低出生體重率」兩項指標之數據惡化。另臺灣三年度二氧化碳超量排放皆為344%，並未改善，而吉尼係數顯示貧富不均小幅加劇。 建議：(1) 強化我國兒童指標統計專區，以生命歷程觀點、解構數據等原則管理指標，補充5歲以下兒童死亡率、5歲以下兒童發展遲緩盛行率、青少女生育率、兒童道路傷害死亡率、自殺死亡率以及學業能力等資料，並進行統計資料庫間的基礎數據比較研究，精確捕捉我國兒童發展遲緩、青少女生育率及親密伴侶施暴等數據。(2) 將兒童納入所有政策：「兒童蓬勃指數」各項指標在我國多有對應主責部會，然而為改善兒童基本生存環境、婦幼健康、兒童心理健康、環境永續及公平性，需要透過跨部門合作，規劃以兒童為中心的公共政策。因此，建議應破除現在指標主責部會由統計數據來源機關擔任之思維，改列與決定因素有關的部會，以落實「將兒童納入所有政策」(Children in All Policies 2030, CAP-2030)之倡議。(3)進一步分析不同亞群兒童在「兒童蓬勃指數」之表現，未來可加以驗證《兒童權利公約》是否有助我國兒童健康福祉；最後，發展質性研究，探索兒童對於健康福祉指標之意見。

Background: The United Nations adopted the 'Convention on the Rights of the Child' (CRC) in 1989. 'Child’s right to health' stipulated in Article 24 not only requests states parties to provide the necessary medical and health care, but also consider social, environmental, and other determinants of health. Taiwan government implement CRC through the 'Implementation Act of the Convention on the Rights of the Child' in 2014. Few studies have discussed the association between implementation of the Act and children’s health and well-being. The World Health Organization, the United Nations Children's Fund (UNICEF), and 'The Lancet' developed the 'Child Flourishing Index' (CFI), which evaluates children’s health and well-being from the United Nations Sustainable Development Goals, children’s rights, environmental sustainability and equity. Therefore, the aims of this study are to construct Taiwan's CFI, and assess children's health and well-being after implementation of the CRC through cross-country and multi-year comparison. Methods: This study used the comparative analysis and the secondary analysis to calculate the CFI’s indicators through the databases of the Institute for Health Metrics and Evaluation (IHME) and Taiwan's official statistics. In addition, Taiwan's CFI was compared with nearby countries such as South Korea, Japan, and Singapore. Also, it carried out a comparison of CFI's indicators in 2017 and 2020, based on the indicators in 2014. Results: The CFI includes indicators of surviving dimension, thriving dimension, excess CO2 emissions and Gini coefficient. The results of this study are as follows: (1) Taiwan's CFI overall score is 0.9 in 2017. The rank of the overall score, survival dimension, and thriving dimension among the 180 countries are the top 24, the top 34, and the first with other 7 countries respectively. (2) In the cross-country comparison, Taiwan’s CFI overall scored 0.9, which is behind South Korea, Japan, and Singapore, and the performance on these indicators needs to be improved: under 5 mortality rate, maternal mortality ratio, death due to road injuries for ages 0-19 years, the incidence of low birth weight, the prevalence of stunting among children under 5 years of age, and proportion of young women and men aged 18-29 years who experienced sexual violence by age 18. (3) In the multi-year comparison of Taiwan, this study noticed the deuteriation in the suicide mortality rate for ages 15-24 and the incidence of low birth weight. Furthermore, the excess CO2 emissions remained at 344%, and the Gini coefficient shows a rising inequity slightly. Suggestions: (1) Strengthen Taiwan's Child Stats. From the principles of life course perspective and presenting disaggregated data; moreover, to increase the indicators such as under 5 mortality rate, stunting prevalence, adolescent birth rate, child road injury mortality, suicide mortality, and academic achievement, and to strengthen the comparison study of basic data from different sources. (2) Children in all policies: Various indicators of CFI correspond to the responsible departments in Taiwan, but most of them are the sources of statistics data. In order to improve children’s living environment, maternal and child health, children’s mental health, environmental sustainability and equity, it is necessary to strengthen cross-departmental collaboration to design children-centered public policies. In line with the initiative of “Children in All Policies, 2030”, this study suggested that strengthen the cross-departmental collaboration to design children-centered public policies, and all ministries related to the health of determinants must be the responsible departments of CFI indicators. (3) To further assess the CFI of children with disabilities, indigenous children, and poverty, and continue to collect process and outcome indicators to verify whether the CRC contributes to the health and well-being of children in Taiwan. Last but the least, to explore children's opinions on indicators of health and well-being with qualitative research.