ArticlesReduction in child mortality in Niger: a Countdown to 2015 country case study
Introduction
Countdown to 2015 for maternal, newborn, and child survival1 reported in its 2012 cycle that only 23 of 74 Countdown countries are on track to achieve the Millennium Development Goal 4 (MDG 4), to reduce by two-thirds the mortality rate of children younger than 5 years, between 1990 and 2015. These aggregate statistics are worrisome, and have led to urgent calls for in-depth analyses of the factors that contribute to the performance of a country in scaling-up interventions effective in reduction of maternal, newborn, and child mortality.2, 3 Countdown responded to this need by commissioning a series of in-depth country case studies, of which this is the first.
The Republic of Niger is a landlocked country in western Africa (figure 1). The Sahara Desert covers about 80% of the country, so about 75% of the estimated 15·7 million population4 lives in the five of eight administrative regions, in the far south and west of the country (Tillabéry, Dosso, Tahoua, Maradi, and Niamey). Since its independence from France in 1960, Niger was ruled alternatively by civil and military regimes until a coup d'état, in 2010, established a democratic, multiparty state. The largely subsistence economy is threatened periodically by drought and food insecurity.
Niger is one of the poorest countries in the world, ranking 186 of 187 in 2011 on the Human Development Index.5 Fertility is high, estimated by the 2006 Demographic and Health Survey (DHS) at 7·1 children per woman.6 The macroeconomic situation has not improved, as shown in the gross domestic product (GDP) per head in the past decade, and the percent of households living at or below the poverty level has remained more or less stable.7, 8, 9 Total official development assistance (ODA) increased 77% between 1998 and 2010 (US$421·3 million to $744·5 million).10 Although total ODA decreased from 2003 to 2008, ODA to maternal, newborn, and child health increased greatly during that period (209% increase per livebirth and 474% increase per child), as estimated by Countdown on the basis of data from the Organisation for Economic Co-operation and Development.11 The increases in funding to child health in Niger were attributable to small increases by many donors—many of which had not provided any funding at all in 2003—and larger increases by the GAVI Alliance and the Global Fund especially. Government expenditure on health per head rose from $5·3 in 1998 to $9·1 in 2009, with lows of $4·2 and $4·7 in 2005 and 2006, respectively.12, 13 On the basis of a reanalysis of the 1998 DHS14 and a national mortality and child survival survey (ESM)15 done in 2010 by the Niger National Institute of Statistics (INS), there was only a small increase in the percent of births to women with secondary or higher levels of education, going from 3·2% in 1996–98, to 4·8% in 2008–10. Biodemographic indicators showed little change (appendix).
Countdown invited Niger to do this in-depth analysis of their progress in child survival for several reasons. First, the mortality in children younger than 5 years has plummeted in Niger in recent years, outstripping decreases in neighbouring countries.16 Second, coverage rates for many high-impact interventions monitored by Countdown have shown great increases in Niger, especially since 2005, and the Ministry of Health, the UN Children's Fund (UNICEF), and other partners wanted to confirm and synthesise these results. Finally, since the capacity of the mortality analysis of the National Institute of Statistics (INS) in Niger was expanded in the past 2 years through the Real-Time Results Tracking project, the case study could be done quite rapidly and in country, with leadership by local investigators. INS accepted Countdown's invitation in early 2012, and the Niger Countdown Case Study Working Group was formed with working teams in the areas of mortality, coverage, programme documentation, and contextual factors that could have affected child mortality directly or indirectly by influencing the implementation or effectiveness of child survival interventions.
We explore how Niger achieved these reductions in child mortality. We selected the reference period of 1998–2009 on the basis of the availability of data and because the scale-up of child survival policies and programmes in Niger began in earnest in the early 2000s.
Section snippets
Data sources
For mortality, we identified all available nationally representative survey datasets in Niger that included a full birth history from women of reproductive age (15–49 years) that would allow direct computation of childhood mortality using life table procedures. Available datasets included the 1992, 1998, and 2006 DHSs and the 2010 ESM. We did assessments of data quality on the 2010 ESM with the aim of updating mortality rates to 2009 (appendix) and noted no major issues or discrepancies with
Results
The mortality rate in children younger than 5 years decreased rapidly during 1998–2009 in Niger, from 226 child deaths per 1000 livebirths (95% CI 207–246) in 1998 to 128 child deaths per 1000 livebirths (117–140) in 2009, showing an annual rate of decrease of 5·1% (figure 2). The 95% CIs for the point estimates in 1998 and 2009 do not overlap, indicating a significant decrease. The decrease in neonatal mortality was slow and insignificant in this period, ranging from 39 (95% CI 32–46) to 33
Discussion
New data in 2010 show that Niger reduced its child mortality by 43% between 1998 and 2009, from 226 to 128 deaths per 1000 livebirths. The annual rate of decline was 5·1%, which exceeds the 4·3% needed to achieve MDG 4 for child survival, and is far higher than the rates of neighbouring low-income or middle-income countries such as Benin (2·2%), Burkina Faso (0·8%), Chad (0·9%), Mali (1·8%) and Nigeria (2·0%) as estimated in 2010.1 How has Niger achieved this?
Our findings suggest that three
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