Niger's Triumph

In Niger, death has long been a way of life.

The people of this West African nation endure  pervasive poverty, persistent food shortages and a punishing climate. Especially vulnerable are the young; many children in Niger perish before their fifth birthday.

“Sometimes when you ask people how many children they have, they’ll say, ‘I have five children—three living and two dead,’” says Sarah Dalglish, MA, an International Health (IH) doctoral student.

A new study, however, suggests things have changed. Researchers found a direct connection 
between the country’s child survival policies from 1998 to 2009 and a 43 percent drop in under-five deaths. The mortality rate plummeted from 226 deaths per 1,000 births to 128.

In 2009 alone, the measures saved the lives of nearly 60,000 children.

IH assistant scientist Agbessi Amouzou, PhD, MHS, the study’s lead author, partnered with UNICEF-Niger and Countdown to 2015 on the research. Jennifer Bryce, EdD, a study co-author and IH senior scientist, led the School-based group that analyzed the research data. The findings were published in The Lancet in September 2012.

“Niger … has produced remarkable results for child survival that can set the bar for other countries in the region and worldwide,” says Amouzou.

Posting Health in Communities

Central to Niger’s dramatic child survival gains is the country’s 2000 presidential declaration to deliver more and better health care to women and children—especially in the most rural and remote communities—by ramping up its network of health posts to provide basic preventive and curative care. 

Between 2000 and 2007, nearly 2,000 posts were established and staffed by community health workers trained to treat diseases that are frequently fatal in children. Severe cases are referred to centrally located health centers with professional staff.

During the study period, community workers continued to receive training, and when possible, the posts offered additional services, including nutrition screenings, educating parents on appropriate health care for sick children and distribution of contraceptives.

“If you look at the coverage data on how many children were taken for care for diarrhea, pneumonia and malaria, there are large increases that other countries have not been able to achieve,” says Bryce, who notes that change takes time.   

“Looking for success in two to three years is really not enough time,” she says. “In Niger, it took three, five, seven years for sound policies to translate into strong programs and to save lives.”

No Charge for Mothers & Children

A pivotal piece of Niger’s child survival initiative is a program, launched in 2006, to provide free health care to pregnant women and children. Earlier, expansion of the country’s rural health posts improved geographic access to care and led to steady increases in the use of health services among women and children. But visits to the posts spiked after the no-charge policy took effect, according to the study.  

Removal of the cost barrier meant that mothers received antenatal care and children were treated earlier for life-threatening conditions and illnesses, including Niger’s leading child killers: malaria, pneumonia, diarrhea and malnutrition.

“You can’t separate free care from all the other successes—it underlies everything else,” Dalglish says. “It gets people in the door to treat their children, get vaccinated and diagnose disease.

With Niger’s widespread poverty and a fertility rate of seven children per woman, the country’s health officials recognized free care as a top priority.

“Even very small fees are going to be too expensive for people,” Dalglish says. “It’s particularly true [in Niger], for example, right before the harvest. People have very little or no cash on hand.” 

“A” Powerful Supplement

Niger’s impressive reductions in child mortality refute an old public health maxim that a country must increase its wealth before it improves its health, says Alfred Sommer, MD, MHS ’73, Bloomberg School dean emeritus.

“Since this School was founded, we’ve taken the position that there are ways to improve health, largely through methods that don’t require waiting until a country is wealthy,” says Sommer. “They [countries] can leapfrog ahead by effectively deploying inexpensive, proven interventions, which is critical, since many won’t be getting wealthy anytime soon.”

There’s no better example of a “health before wealth” intervention than vitamin A. Sommer’s discovery that vitamin A supplements dramatically cut child mortality has saved millions of children worldwide.

Integral to Niger’s child survival program are twice yearly mass campaigns to provide vitamin A supplements, along with insecticide-treated bed nets (see next story) and measles vaccinations. Of the strategies analyzed in the study, vitamin A supplementation and bed-net ownership showed the largest increases in usage. 

“The question is, will this be a lasting change?” Sommer says. “While magic bullets are cheap, getting them to the people who need them is not cheap.”

Net Gains Against Malaria

The use of long-lasting, insecticide-treated bed nets is a powerful malaria control weapon, even with a community coverage level just above 50 percent, says William Brieger, DrPH ’92, MPH.

“What’s important is that insecticide-treated nets are a community protection; they don’t just protect individuals,” says Brieger, IH professor and senior malaria specialist at Jhpiego. “If you get enough treated nets being used in a village, you start to see the effects even though not everybody is using them.”  

In Niger, researchers found that the rapid scale-up of treated bed net distribution is responsible for saving one in four children in 2009. 

Still, Brieger says that most demographic surveys on antimalarial nets show that even in households that have nets, the most vulnerable groups don’t use them enough. And there are frequent reports of people using nets for fishing, covering crops and even as wedding veils.

Another challenge relates to the lifespan of the long-lasting, insecticide-treated nets. After an international push for universal bed-net coverage between 2009 and 2011, Brieger says that millions of nets are nearing their expiration date.

“We’re now looking at 2013, and there needs to be a lot of replacements,” he says.