Documentation of Child Survival Interventions, Niger 2000 - 2010 pdf

Documentation of Child Survival Interventions, Niger 2000 - 2010 Niger Countdown Case Study Report from the Documentation Team August 2012 Dr Khaled Bensạd, UNICEF-Niger, Team Leade

Documentation of Child Survival Interventions,

Niger 2000 - 2010

Niger Countdown Case Study Report from the Documentation Team

August 2012

Dr Khaled Bensạd, 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”

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, Bensạd 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)

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

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

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

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

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 Bensạd 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

• 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

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

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