1 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” 2 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). 3 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 4 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. 1 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. 1 The reference period for the overall case study was 1998 to 2009. The documentation team focused on the period 2000 – 2011 . 5 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, 2 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 2 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. 6 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 7 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. 8 • 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. 3 • 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 3 Institut National de la Statistique. Enquete nationale sur les besoins en soins obstétricaux et néonatals d’urgence au Niger. Niamey,République du Niger, 2011. 9 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 10 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. [...]... Utilisation Provision of treatments Midwife to population ratio 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 rate of health service...Annex 1: Work Plan for the Documentation Team WORK PLAN : UNICEF Niger 2011 Activities Week 1 28/05/2012 1 Week 2 04/06/2012 Week 3 11-Jun Week 4 18-Jun Week 5 25-Jun Week 6 02-Jul Week 7 09-Jul Data compilation on child survival activities and contextual factors related to child health and survival in Niger, 200 0- 2011 2 For each data source, use a standard template to... 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... assistance for child health Infrastructure Per Capita spending on child health 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... 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 8 Workshop 11 Week 8 16-Jul Annex 2: Original list of priority... 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... exactly? Where? Who ? Coverage for (Région What each Districts level of intervention village/s health etc.) system? 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? 13 Annex 4: List of key informants interviewed Organization PNLP Name Title Dr... Issoufou Hamsatou Djoffo Suivi évaluation PNLP Mme Ben Nana Suivi évaluation PNLP Mr Alkassoum Zodi Responsable Approvionnement PNLP 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... Ibrahim Mariama kellési Direction des ONG Dr BRAH FERDOS Responsable santé DR ISSA HAMIDOU Responsable santé Cellule Gratuité Ministère du Developement Communautaire CROIX ROUGE Française CROIX ROUGE Nigerienne Dr ARIFA tidjani CONCERN Dr MICHELE SAIBOU Responsable CRS Dr Ibahim Ousmane Coordonnateur Projet Puludisme FM MSF Suisse Dr TOURE KALIL Hamadoun Responsable santé 15 . 1 Documentation of Child Survival Interventions, Niger 2000 - 2010 Niger Countdown Case Study Report from the Documentation Team. 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