title: Niger's Child Survival Success, Contributing Factors and Challenges to Sustainability: A Retrospective Analysis.
abstract: BACKGROUND
  Household surveys undertaken in Niger since 1998 have revealed steady declines in under-5 mortality which have placed the country 'on track' to reach the fourth Millennium Development goal (MDG). This paper explores Niger's mortality and health coverage data for children under-5 years of age up to 2012 to describe trends in high impact interventions and the resulting impact on childhood deaths averted. The sustainability of these trends are also considered.
  
  
  RESULTS
  Estimates of child mortality using the 2012 Demographic and Health Survey were developed and maternal and child health coverage indicators were calculated over four time periods. Child survival policies and programmes were documented through a review of documents and key informant interviews. The Lives Saved Tool (LiST) was used to estimate the number of child lives saved and identify which interventions had the largest impact on deaths averted. The national mortality rate in children under-5 decreased from 286 child deaths per 1000 live births (95% confidence interval 177 to 394) in the period 1989-1990 to 128 child deaths per 1000 live births in the period 2011-2012 (101 to 155), corresponding to an annual rate of decline of 3.6%, with significant declines taking place after 1998. Improvements in the coverage of maternal and child health interventions between 2006 and 2012 include one and four or more antenatal visits, maternal Fansidar and tetanus toxoid vaccination, measles and DPT3 vaccinations, early and exclusive breastfeeding, oral rehydration salts (ORS) and proportion of children sleeping under an insecticide-treated bed net (ITN). Approximately 26,000 deaths of children under-5 were averted in 2012 due to decreases in stunting rates (27%), increases in ORS (14%), the Hib vaccine (14%), and breastfeeding (11%). Increases in wasting and decreases in vitamin A supplementation negated some of those gains. Care seeking at the community level was responsible for an estimated 7,800 additional deaths averted in 2012. A major policy change occurred in 2006 enabling free health care provision for women and children, and in 2008 the establishment of a community health worker programme.
  
  
  CONCLUSIONS
  Increases in access and coverage of care for mothers and children have averted a considerable number of childhood deaths. The 2006 free health care policy and health post expansion were paramount in reducing barriers to care. However the sustainability of this policy and health service provision is precarious in light of persistently high fertility rates, unpredictable GDP growth, a high dependence on donor support and increasing pressures on government funding.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.
authors.forename: Donela
authors.initials: D
authors.lastname: Besada
authors.affiliation: Saving Newborn Lives/Save the Children, Cape Town, South Africa.
authors.forename: Kate
authors.initials: K
authors.lastname: Kerber
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.
authors.forename: Natalie
authors.initials: N
authors.lastname: Leon
authors.affiliation: School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Cape Town, South Africa.
authors.forename: David
authors.initials: D
authors.lastname: Sanders
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Daviaud
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.
authors.forename: Sarah
authors.initials: S
authors.lastname: Rohde
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.
authors.forename: Jon
authors.initials: J
authors.lastname: Rohde
authors.affiliation: School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Cape Town, South Africa.|Institute of Tropical Medicine, Sint-Rochusstraat 2, 2000, Antwerpen, Belgium.
authors.forename: Wim
authors.initials: W
authors.lastname: van Damme
authors.affiliation: Saving Newborn Lives/Save the Children, Cape Town, South Africa.
authors.forename: Mary
authors.initials: M
authors.lastname: Kinney
authors.affiliation: Biostatistics Research Unit, South African Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001, South Africa.
authors.forename: Samuel
authors.initials: S
authors.lastname: Manda
authors.affiliation: UNICEF Head office 125 Maiden Lane, 11th Floor, New York, NY, 10038, United States of America.
authors.forename: Nicholas P
authors.initials: NP
authors.lastname: Oliphant
authors.affiliation: UNICEF Niger, 2, rue des Oasis - Quartier Ancien Plateau, Niamey, Niger.
authors.forename: Fatima
authors.initials: F
authors.lastname: Hachimou
authors.affiliation: UNICEF Benin, 01 BP 2289 Cotonou Boulevard de la CEN-SAD, Cotonou, Benin.
authors.forename: Adama
authors.initials: A
authors.lastname: Ouedraogo
authors.affiliation: Ministry of Health, BP 613, Niamey, Niger.
authors.forename: Asma
authors.initials: A
authors.lastname: Yaroh Ghali
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive, Parow, Cape Town, 7535, South Africa.|School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, 7535, Cape Town, South Africa.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
mesh_terms: D000067576:Child Health / Q000639:trends*; D046688:Child Mortality / Q000639:trends*; D002675:Child, Preschool; D005260:Female; D006306:Health Surveys; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D000068097:Maternal Health / Q000639:trends*; D009548:Niger; D012189:Retrospective Studies