UNIVERSITY OF PORT HARCOURT CHILD SURVIVAL IN RESOURCE- LIMITED SETTINGS: THE ISSUES, CHALLENGES AND WAY FORWARD An Inaugural Lecture By PROF. ALICE ROMOKEK NTE [MB.BS (Ibadan); FWACP] Department of Paediatrics and Child Health, Faculty of Clinical Sciences, College of Health Sciences. INAUGURAL LECTURE SERIES NO. 91 AUGUST 9, 2012 i DEDICATION First, this work is dedicated to my Lord and Saviour, Jesus Christ, who has made this lecture possible. Second, this lecture is dedicated to my late parents-Mr. Bertram and Mrs. Margaret Robert Ikuru and my late grandparents- Chief Jonas and Mrs. Zilpha Minini Oyo whose unwavering commitments to my survival, growth and development have brought me this far. Third, this lecture is dedicated to my children-Abraham, Deborah, Emmanuel and Daniel and several Nigerian children that provided me the opportunities to prove that the interventions I have presented in this document are effective in ensuring child survival. Lastly, this lecture is dedicated to the memories of the several children who died as under-fives and their parents who endured the agonies of these largely preventable child deaths. ii ACKNOWLEDGEMENTS I wish to express my gratitude to the Almighty God who has led me this far and, I am sure, will sustain me to the end. I am indebted to my late parents-Mr. Bertram and Mrs. Margaret Robert Ikuru, and my late grandparents-Chief Jonas and Mrs. Zilpha Minini Oyo for their unwavering commitments to our survival. I also appreciate my uncles and aunties [Late (Mr. Owen Tobiah, Mrs. Comfort S. Mark, Mrs. Marion Brown and Karina Minini), Chief Jonas Gogo Minini Oyo, Mr. David D. Minini and Sir Blessing B. Minini], cousins and other close family relations for their roles in ensuring my survival, growth and development and their continued support. My sibs (Sir (Eng.) Emiyarei B. Ikuru, Mrs. Edith Ijente, Osake, Chief (Bar) Metong Urombo, Sir Belejit Ikuru, Dr. Amaijaan Ikuru, Kachei, Esther, Tele, Robert, Titus, Mary, Ijok, Nteonyiro and Margaret), their spouses and children have continued to ensure we lived as a loving united family. I appreciate all your contributions to my existence. My paternal uncles- Late Papa Julius Urombo, Late Papa Justus Hebron, Late Papa Levi Charles Arawo and Mr. Obediah Ijije and their children are highly appreciated for their supportive roles in my life. My husband, Dr. Augustus Romokek Nte, and our children- Abraham Awaji- Inwon, Deborah Atata-Nwon, Emmanuel Awaji-owa and Daniel Awaji –Itong who have been of tremendous support to me are highly appreciated. My parents in-law- Late Sir Fortunatus and Mrs. Joyce Nte and my in-laws iii (Mrs. G. Nwadike, Madam Theresa Owo, Sir Dan Gogo Ukoikpoko, Dr. Felix Nte, Mrs. Comfort Iragunima, Vincent, Kate, Dr. Timothy Nte, Eng. Peter Nte and Lucy are also acknowledged with their spouses and children. My wonderful relations who have lived with me and supported me through different periods of my development- the girls- Flora, Faith, Esther and Gold are appreciated for their dedicated services. I acknowledge the commitments and hard work of my teachers at the different levels of my education whose contributions are part of the reason for today’s celebration. Some exceptional ones among them are Late Mrs. Aurelia Otowo, Mrs. Ekpor, Mrs. Mary Collette Akwaowo (nee Anwah), Prof. Desalu and Prof. Jayeisimi. My appreciations also go to my consultants during the Residency Training Programme and several other colleagues who in one way or the other impacted on my career, among whom are Emeritus Prof. N.D. Briggs, Prof. R.S. Oruamabo, Prof. D. D. Datubo- Brown, Prof. Angela Okolo, Prof. Ifeoma Egbuonu, Prof. K. E. O. Nkanginieme and Dr. Lucy Yaguo Ide. Other special persons who have affected my life and are hereby acknowledged include Late Mr. B. Ukotije and Mrs. Ukotije, Late Rev. (Eng.) E.W.U. Essiet, Chief (Dr.) Silas Eneyo, Rev. (Eng.) Amangi D. Peters, Rev. (Eng.) Femi Akinola, Rev. Obakpolor, Rev. Ezenekwe Allen. My colleagues in the Department of Paediatrics at the University of Port Harcourt Teaching Hospital and the University of Port Harcourt, the Faculties and College of Health Sciences, the Institute of Maternal and Child Health, the University and the West African College of Physicians and Paediatricians in general deserve special thanks for their various roles in my life. iv The Media practitioners- especially those in Rivers State Television Authority (Mr. Obele Chu and Mrs. Orisalem Dokubo) and the Africa Independent Television (Ms Nengi Finecountry) are appreciated for their contributions to my community enlightenment programmes. The different partners at the Federal Ministry of Health, United Nations Children’s Fund, World Health Organisation, West African Health Organisation, Rivers State Ministry of Health, the Chairman, Andoni LGA Council, Hon. Orom Nte and several other persons with whom I have closely worked are appreciated. The parents and caregivers (grandparents, aunties/uncles and maids) who have painstaking supported the upbringing of children are also acknowledged. I cannot complete this acknowledgement without thanking my bosses- the Vice Chancellor, Prof. Joseph Ajienka and the University Management, the past Vice Chancellors and Registrars of the University, the past and current Provosts of the College of Health Sciences, Deans and Heads of Departments in the College, the current (Prof Aaron Ojule) and past Chief Medical Directors of the University of Port Harcourt Teaching Hospital and the Hospital Management. The opportunities for service they gave me contributed to the story I am telling today. Alice Nte v ACRONYMS % Percent ACSDP Accelerated Child Survival and Development Programmme AIDS Acquired Immunodeficiency Syndrome ARI Acute Respiratory Infection C-IMCI Community Integrated Management of Childhood Illness GNI Gross National Income Hib Haemophilus influenza type b vaccine HIV Human Immunodeficiency Virus IMCI Integrated Management of Childhood Illness IMNCH Integrated Maternal, Newborn and Child Health IMR Infant Mortality Rate LGA Local Government Area MDG Millennium Development Goal vi MSS Midwives Service Scheme NMR Neonatal Mortality Rate SSA sub-Saharan Africa UHC Universal Health Coverage U5 Under-five U5MR Under 5 Mortality Rate UNICEF United Nations Children’s Fund US$ United States of America’s Dollar WAHO West African Health Organisation WHO World Health Organisation vii Preamble The Vice Chancellor, Sir, it is with gratitude to God, you and your Management team that I stand here to present a lecture on a topic so dear to my heart- Child Survival. Psalms 127: 3 says- Children are an heritage of the Lord and the fruit of the womb is his reward (King James Version of the Bible). This highlights the value God attaches to these precious jewels and why we must do everything possible to keep them alive. This, Mr. Vice Chancellor Sir, is one of the driving forces for the choice of this inaugural lecture’s topic- CHILD SURVIVAL IN RESOURCE- LIMITED SETTINGS: THE ISSUES, CHALLENGES AND WAY FORWARD 1. Introduction Child survival is not only of global concern but it is of concern in all cultures, races, religion, tribes and peoples. Thus, at the 1990 World Summit for Children, World leaders, in their Plan of Action identified the following specific actions for child survival, protection and development-the Convention on the Rights of the Child, Child health, Food and nutrition, Role of women, maternal health and family planning, Role of the family, Basic education and literacy, Children in especially difficult circumstances, Protection of children during armed conflicts, Children and the environment, Alleviation of poverty 1 and revitalization of economic growth. They also identified Follow-up and Monitoring Actions at the national and international levels. Probably because of the uncertainty of the survival of the child in the most risky first few days of life, many cultures do not name the newborn till a few days to months after birth; and, in spite of the Convention on the Rights of the Child and related States, National and Regional documents reiterating the right of the child to a name from birth, this practice has persisted. Bearing in mind that "the child, by reason of his physical and mental immaturity, needs special safeguards and care, including appropriate legal protection, before as well as after birth", and that the under-five mortality rate reflects the functional state of various services in a country and not just health, there is need for all stakeholders to pay attention to the issue of Child Survival. However, because under-five mortality rate is not readily influenced by values obtained from the well- to-do settings, to ensure child survival, the leadership in resource-limited settings must be more accountable and utilize available resources to the maximal benefit of all children and their mothers and not just the privileged few. They must ensure that the means to realise these rights are accessible (socially, economically, geographically, culturally, etc), of good quality and provided on a sustainable basis. Can leaders at all levels in resource-limited settings such as Nigeria prescribe, legalise and implement punishments for themselves if by their acts of omission or commission, a child’s right to survival is threatened? Can the governed in such settings demand for good governance bearing in mind that at least 60% of the total 2 7.6 million under-five deaths estimated for 2010 could have been prevented since their common causes pneumonia, diarrhoeal diseases, preterm birth complications and birth asphyxia are preventable or treatable using currently available, evidence-based, effective and low cost interventions which do not require the development of elaborate or expensive new technologies but can be and have been successfully implemented even in the poorest of settings? I do hope that at the end of this lecture, we shall be committed to ensuring we do our best to promote child survival, growth and development in Nigeria specifically and in resource-limited settings in general. In deed as indicated by the WHO Regional Director in his Report on Child Survival: A strategy for the African Region, the key to making progress towards attaining Millennium Development Goal(MDG) 4 by 2015 is reaching every newborn and child in every district with a limited set of priority interventions. This is the reason for my focus on resource-limited setting- every child in every district must be reached. 2. Explanations/Definitions of terms To fully understand the topic of our discussion, I shall explain some of the key terms: a. Child: every human being below the age of eighteen years unless under the law applicable to the child, majority is attained earlier (Convention on the Rights of the Child). 3