Documentation of Child Survival Interventions, Niger 2000 - 2010 pdf

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Documentation of
Child Survival Interventions,
Niger 2000 - 2010


Niger Countdown Case Study
Report from the Documentation Team
August 2012

Dr Khaled Bensaïd, UNICEF-Niger, Team Leader
Dr Helenlouise Taylor, Consultant
Dr Maazou Abani, Ministry of Health


The documentation results are available in a separate excel workbook
titled “Child Survival at a Glance 2000-2011”




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This work was conducted as a part of an in-depth case study supported by Countdown to
2015 for Maternal, Newborn and Child Survival. Other components of the case study

focused on reductions in under-five and neonatal mortality, changes in nutritional status and
coverage for high-impact interventions, and contextual factors that may have affected child
survival. The results of the case study are reported in Amouzou A, Habi O, Bensaïd K and
the Niger Countdown Case Study Working Group, “Reduction in child mortality in Niger: a
Countdown to 2015 country case study”, Lancet 2012; 380, In Press.
The case study was supported through the Countdown to 2015 for Maternal and Child
Survival by the Bill & Melinda Gates Foundation, the World Bank and the Governments of
Australia, Canada, Norway, Sweden, and the UK. We thank the Government of Niger and
especially the Ministry of Health for their assistance in compiling, reviewing, and interpreting
the data presented here. The work could not have been done without the full support of
UNICEF-Niger, its Country Representative (Guido Cornale) and Deputy Representative
(Isselmou Boukhari).


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Table of Contents

1. Background and objectives 4
2. Methods 4
3. Results 6
4. Limitations and constraints 6
5. Conclusions and recommendations 8
Annexes
1. Work Plan for the Documentation Team
2. Original list of priority information for documentation
3. Guide for interviews with key informants
4. List of key informants interviewed

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1. Background and objectives
This is the first in a series of in-depth country case studies commissioned by the Countdown
to 2015 for Maternal, Newborn and Child Health (“Countdown”), and focuses on child
survival in Niger. A study group was formed to do the case study, with working teams in the
areas of mortality, coverage, program documentation, and contextual factors that could have
affected child mortality directly or indirectly by influencing the implementation or
effectiveness of child survival interventions. This document summarizes the work of the
program documentation team.
The team was responsible for documenting child survival policies, programs and contextual
factors in Niger from 2000 to 2011.
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The specific objectives for this component of the work
were:
1. To develop an excel workbook containing information on policies and programs
related to child survival during the reference period, including tables and graphs
where relevant, and an accompanying brief report.
2. For each data source, to use a standard template to assess data quality and
completeness.
3. To develop a resource file and annotated bibliography containing all relevant
documents and data, organized to support replication of the findings.
4. To participate in the case study analysis and preparation of the case study report.

2. Methods
The documentation work was carried out in Niamey, Niger between May and July, 2012.
The work plan developed by the team is available in Annex 1.
2.1 Scope of the review
Content. Members of the Niger Countdown Case Study working group met in Baltimore in

May 2012 and developed a preliminary list of the types of information and indicators that
should be included in the documentation report (Annex 2). This list was modified based on
the availability of data and additional information and indicators defined by the
documentation team.

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The reference period for the overall case study was 1998 to 2009. The documentation team focused on the
period 2000 – 2011 .

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The focus of the review was defined in three dimensions: time period, intervention and
coverage. The time period was 2000 to 2011. For interventions, we focused on
interventions effective in reducing maternal, newborn and child mortality as defined in a
recent global review,
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as listed in Annex 3. Coverage was defined for each intervention, and
included a range of denominators depending upon the available data (i.e., villages, districts,
regions, hospitals, health centres, health posts, community health workers, health workers,
pregnant women and children younger than five years of age). We took special care to
define the denominators for all reports of coverage, because many documents identified in
the review reported only regional or district coverage that suggested higher levels of
coverage.
2.2 Document search
The team carried out a document search for all national policies, strategies, plans and
budgets and project documents using internet searches, key informant interviews and visits
to Government Ministries and partner offices. All documents are available on the UNICEF-
Niger website.
. The Ministries visited were: Ministry of Community Development, Ministry of Water and the
Ministry of Health. Within the Ministry of Health we visited: the Division of Reproductive

Health; the Departments of Nutrition, Child Health, Maternal Health, and Prevention of
Maternal to Child Transmission of HIV, Organisation of Clinical Services, Free Health Care,
Program Oversight (DEP), Documentation Service and Health Information System (SNIS);
the Expanded Program on Immunisation and the National Malaria Control Program.
We selected UN agencies (Niger offices) and NGOs that were active in child and newborn
survival programs between 2000 and 2010, based on the knowledge of team members and
reports by key informants. We visited the UN Office for the Coordination of Humanitarian
Affairs, UNICEF, the World Health Organization and the UN Population Fund (UNFPA), as
well as Save the Children, Concern, Niger Red Cross, French Red Cross, Medecins Sans
Frontieres Suisse and Catholic Relief Services.
2.3 Key informant interviews
We conducted semi-structured interviews with 40 key informants both within and outside the
organizations visited. Annex 3 contains the interview guide; Annex 4 lists the key informants.
2.4 Data quality assessments and development of the summary tables

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The Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key
Interventions Related to Reproductive, Maternal, Newborn and Child Health (Rmnch ). Geneva,
Switzerland: PMNCH.

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All information was reviewed by the full documentation team prior to inclusion in the
summary tables. Where there were discrepancies, we reviewed the original sources and
when necessary tried to re-interview key informants to reconcile them, although all
information was retained in the spreadsheets. Where raw data sets were available we
recalculated quantitative indicators. The team tried to complete missing data where
possible.
An excel workbook was constructed to summarize all the documentation information. The
workbook includes 14 worksheets summarizes information related to specific diseases and

categories of child deaths, as well as additional worksheets providing major policy and
program milestones and characteristics of the health system. Each of these sheets contains
information on interventions related to the topic area. For example, water and sanitation
interventions and activities to promote hand washing are included in the diarrhoea
worksheet. For each intervention we summarize activities related to prevention, case
management, equipment and availability of necessary drugs. The worksheets also include
official Government reports of intervention coverage as well as morbidity, mortality and
nutritional status, To make sense of the large volumes of information, the team put the data
together in the form of a history or story (i.e., “…and then what happened?” This enabled
missing pieces of the puzzle to be identified.
The final workbook was reviewed for accuracy with the Ministry of Health.

3. Results
All information and data collected by the documentation team are available in a separate
excel workbook titled “Child Survival at a Glance 2000-2011”. The information in the
workbook can be considered as available for public access because it has all been
published elsewhere.

4. Limitations and constraints
The time allowed for this extremely important exercise was unrealistically short. There was a
delay of one month in beginning the fieldwork, which had to be completed prior to the
meeting of the larger Case Study Working Group in July, 2012.
4.1 Access to data and documents

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Little information was available for the period 2000-2002, and information for 2002-2005 was
difficult to find. Documents were not classified or organized by subject or by year. The team
worked their way through mountains of unclassified dusty materials, often unearthing very
important documents.

In all institutions and Departments there was a lack of institutional memory. No handover
from departing to joining staff seems to have been carried out. We were therefore only able
to collect data from interviewees starting from the date on which they took up their post. The
personal contacts of team members enabled us to take shortcuts and gain rapid access to
information and data if they were available. K. Bensaïd has been working with UNICEF-
Niger for many years and is well respected by Government and partners. M. Abani was a
former coordinator of the Malaria Control program in Niger as well as a District Medical
Officer, and HLT had worked with WHO Niger 2005-2006 in the EPI and Surveillance
programs in the Regions of Maradi and Diffa.
It was difficult to access many of the documents even if referenced elsewhere. We often had
to make multiple visits to an organization to obtain information.
Multiple copies of the same documents from differing sources were found , often with several
“final” versions. This frequently led to confusion when comparing, verifying and checking the
data included in tables and graphics.
The data collection was carried out during school holidays and some expatriate members of
staff were unavailable.
4.2 Quality of Data
There were important limitations in the available information on child survival programs. We
highlight some of the most important of these problems below:
• Incomplete data. This was especially the case for nutrition data prior to 2009. In the
“child survival at a glance” worksheet, all missing values are highlighted in pink.
• Non-concordance of the same data from multiple sources. In such cases all values
were retained in the worksheets, because the team were often unable to assess
which value was correct.
• Denominators quoted in official sources give much higher coverage values than
survey data. This is due to the fact that denominators are based on the National
Census for 2000. In the Region of Diffa, especially, many villages were omitted from
this census.

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• Decentralization of data. Some information is held at regional or district levels and
was therefore not available to the documentation team. This was particularly true of
detailed information about coverage of persons trained, or spending on health. The
limited time frame for this exercise did not permit us to collect and compile data
available only at regional or district levels.
• Few and incomplete data on newborns or newborn interventions. For example,
District Hospitals did not report neonatal deaths in the early years of the reference
period. Even in a recent health facility assessment of obstetric and newborn care,
data on deaths in neonates with birth weights greater than 2.5 kgs are missing.
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• Definitions of indicators . The use of terms such as prenatal care and postnatal care
are constant in documents and reports during 2000-2010, but the content included
under these headings (what and when) changes over time.
• Use of non-standard indicators. Several indicators used over the past decade in
Niger are not consistent with the global consensus indicators as defined by
Countdown and the UN. This is understandable given that these indicator definitions
have changed over time, but presents important challenges to program
documentation.
• Variable completeness of data by program. Malnutrition data before 2007 are
incomplete and of poor quality, documenting only a handful of deaths per year
related to malnutrition. From 2009 onwards the data were more reliable. In contrast,
we found that data on vaccination programs were of better quality earlier in the
decade, and both the EPI program and UNICEF were able to provide us with raw
data sets for reanalysis. Malaria data were also complete from 2005-11, but
intermittent preventive treatment prior to 2008 is for a single dose and not two doses
as in the standard indicator.
• The quality of the Annuaires Statistiques. The completeness of routine reporting
improves each year beginning in 2006. The Annuaire for 2011 was not available.

4. Conclusions and recommendations

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Institut National de la Statistique. Enquete nationale sur les besoins en soins obstétricaux et
néonatals d’urgence au Niger. Niamey,République du Niger, 2011.

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We have limited this section to the documentation component of the case study. The
Ministry of Health, UNICEF and other development partners can use these results as the
basis for discussions about how to improve the effectiveness of their programs.
The documentation process was challenging. However, the Ministry of Health, UNICEF and
other partners all welcomed the effort to document program activities, and to link them to
results in terms of coverage and mortality.
We noted that despite the positive results overall, many high impact interventions have
relatively poor coverage in selected health facilities, districts and regions. A closer
examination of the results will be useful in continuing to pursue the aim of universal
coverage for child survival interventions. Our conclusion is that there is considerable room
for further reductions in child mortality. Particular gaps we noted were in interventions for the
newborn and for water and sanitation.
This documentation exercise also highlights missed opportunities. Well child visits for
children under one year of age, for example, could include immunisation and an assessment
of nutritional status. Antenatal visits could be used to provide all available, effective, age-
appropriate interventions including physical assessment of the woman, prevention of malaria
with drugs and distribution of bed-nets, iron and folate, and counselling and testing for HIV,
with follow up for PMTCT for positive women,. Newborns could be given their first
vaccinations prior to discharge, and those born to HIV mothers treated with ARVs and their
mothers provided with a plan for follow up.
Future case studies can learn from this first experience in Niger. We have the following

suggestions:
 The time allowed to complete the documentation component of the work should be
between two and three months, and longer if information is needed from regional or
district levels.
 The documentation team should include members who are knowledgeable about the
country and the health system, and whose technical expertise is sufficiently broad to
cut across sectors and across vertical programs.
 It would be useful to convene a one-day meeting with stakeholders to explain the
rationale and methods at the start of the documentation exercise, and to present a
list of documents needed to carry out the work. A second meeting would also be
useful to present preliminary results and to identify missing or incomplete information
and to clear up any inconsistencies in the information identified by the documentation
team. A third and very important meeting would provide an opportunity for the

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documentation team to present their results and have them confirmed by
Government and other stakeholders. This would also provide an opportunity for
discussion of potential program actions to be taken in response to the results.
 The Government of Niger may want to consider updating their HMIS and its data
collection forms to include newborn mortality in hospitals, the number of newborns
weighed, and the weight recorded.
 It would be useful if routine indicators were reviewed and revised to conform to global
consensus indicators.


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Annex 1: Work Plan for the Documentation Team

WORK PLAN : UNICEF Niger 2011


Activities
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8



28/05/2012
04/06/2012
11-Jun
18-Jun
25-Jun
02-Jul
09-Jul
16-Jul












1

Data compilation on child survival activities and contextual factors related to
child health and survival in Niger, 2000-2011.





2
For each data source, use a standard template to assess DATA QUALITY
AND COMPLETENESS






3
Develop resources files and annotated bibliography containing all relevant
documents and data, organized to support replication of the findings.



4
Conduct key informant interviews with current stakeholders and those
involved in child survival activities in Niger since 2000

5
Prepare tables and graphs presenting documentation data and information,
by year since 2000



6
Circulate tables and graphs









7
Draft a full report and circulate for review and comment.








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Workshop

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Annex 2: Original list of priority information for documentation

Indicator/Type of Information
Health Policies
Improved access to health facilities
Free Health Care

Nutrition
Vaccination
Treatment of malaria
Community case Management of the Sick Child
Child Survival
Health Financing
Budget allocated to health in relation to the overall Government budget
Finance for Free health care
Out of pocket payments
Funding from partners
Government funding
Official development assistance for child health
Per Capita spending on child health
Infrastructure
Number of centres for nutritional rehabilitation
Number of functional health posts
% of the population within 5km from a health facility
Ratio of health facilities to population
Human Resources
Number of community health workers by Region
Number of community health workers trained in community case management for the sick
child
Population per health facility
doctor to population ratio
Nurse to population ratio
Community health worker to population ratio
Midwife to population ratio
Provision of treatments
Number of long-life insecticide treated bed-nets
Number of doses of Vitamin A

Number of doses of Measles Vaccines
Number of doses of paediatric ACTs for malaria treatment.
Number of treatments of cotrimoxazole antibiotic
Number of oral rehydration salt treatment sachets
Number of treatments of zinc for diarrhea
Utilisation
Utilisation rate of health service by the under fives


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Annex 3: Guide for interviews with key informants
3:Conduct key informant interviews with current stakeholders and
those involved in child survival activities in Niger since 2000, to
introduce the analysis, check on data sources and data quality, and
obtain further documentation. Keep records of interviews and
information obtained. Ensure correct denominator is used and
document it. (hospital CSI villages Districts etc)
Date

Partner

Interview with:





Telephone
Number:

Year
Interventions
What exactly?
Where?
(Région
Districts
village/s
etc.)
Who ?
What
level of
health
system?
Coverage for
each
intervention

Key observations
Why do you think that
the child mortality
rates have fallen??








What do you think

needs to happen to
decrease child
mortality further?















Do you have any
comments or
observations on the
quality of data?

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Annex 4: List of key informants interviewed

Organization Name Title
PNLP
Dr Hadiza Jakou
Coordonnatrice PNLP

Mr Issa Amadou
Responsable Suivi Evaluation PNLP

Mme Issoufou Hamsatou
Djoffo Suivi évaluation PNLP

Mme Ben Nana
Suivi évaluation PNLP

Mr Alkassoum Zodi
Responsable Approvionnement PNLP
OMS
Dr GERVAIS
EPI / TL OMS

Dr Adamou Balkissa
point Santé de la reproduction

Dr Habi Gado
Point focal Paludisme

Mr Bachir
Documentaliste

Mr Harou
EPI
Save the Children
JEFF KALALU
Responsable Santé
OCHA
Clement Karuge

URC
Dr Amsagana Maina Boukar
Directeur URC NIGER
SNIS
Mr Boubacar Adakal
Directeur des Statistique MSP

Mr Komblo Ibrahim
Statistiques MSP

Mr Ibrahim Ousmane
Statistiques MSP

Mr Zaneidou
Responsable MDO
DGSR Dr Asma Gali YARO
Directrice Générale Santé de la
Reproduction

Dr Harakoye Aissata
Directrice Santé mère Enfant

Dr Diata Aissa
chef division PCIME

Mme Adamou Hamsa
Divison PCIME

Mme Hadiza Souna
Chef division PTME

Dr Nassirou Ousmane
Chef division Santé de la reproduction

Mme Mounkaila Habsatou
Traoré Suivi évaluation santé de la reproduction

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Organization
Name
Title
Nutrition
Dr Halarou Aboubacar
Direction nutrition

Mme Lamissi
Direction nutrition

Mr Batouré
Direction nutrition
DEP/MSP Ousmane Oumarou
Directeur des Etudes et Planification
(DEP)

Begou
Agent DEP
Cellule Gratuité
MSP Mr Ibrahim Cellule gratuité (DOS)
DI / PEV / MSP
Dr Hamadou Ousseini
Chef division immunisation MSP

Mr Maiga Moustapha
SUIVI evaluation Division Immunisation

Mr Idé Insa
Suiv évaluation Division Immunisation
Ministère du
Developement
Communautaire
Mme Ibrahim Mariama kellési Direction des ONG



CROIX ROUGE
Française Dr BRAH FERDOS Responsable santé
CROIX ROUGE
Nigerienne DR ISSA HAMIDOU Responsable santé

Dr ARIFA tidjani

CONCERN
Dr MICHELE SAIBOU
Responsable
CRS
Dr Ibahim Ousmane
Coordonnateur Projet Puludisme FM
MSF Suisse
Dr TOURE KALIL Hamadoun
Responsable santé