Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study.

With a population over 15 million people in 2011, the Republic of Niger is West Africa’s second–largest country [1]. This landlocked country is characterized by chronic food security issues, natural crises, including droughts, floods and locust infestation, and a level of poverty that reflects more than a decade of periodic political instability. Niger’s poverty rate of 46.3% makes it one of the world’s poorest countries. Per capita income, at $360, puts it at the very bottom of the 187 countries ranked by the United Nations Development Program’s Human Development Index [2]. In this fragile nation, women and children suffer the greatest burden of poor health and inequality [3]. Niger’s social indicators have improved significantly over the past two decades, as progress toward the Millennium Development Goals (MDGs) is a main priority of the government. The Government of Niger’s policies in support of universal access, provision of free health care for pregnant women and children, and strong nutrition programs have enabled the country to decrease child mortality at a pace that exceeded expectations. These policies are enshrined in general principles and international strategies such as primary health care and the Bamako Initiative. Thus, its health system is organized into three administrative and service levels: local/district, intermediary/regional and central/national. At the local level, public sector services are provided by community health posts (Case de Sante), integrated health centers (Centres de Sante Integres), and district hospitals. About 75% of health posts are staffed by CHWs (the rest by a nurse or midwife), and health centers and hospitals are staffed by at least one nurse, midwife or physician. Recently, the Niger countdown case study showed far greater reductions in child mortality than in neighboring West African countries. In tandem with its efforts to tackle malnutrition, the government of Niger has put in place several measures to reduce childhood mortality. For the past few years, children under five have received free health care, while significant progress has been made in immunization coverage, recruitment of health staff and in the number of malaria cases treated. Collectively, these factors have contributed to a rapid reduction in the under–five child mortality rate, from 226 deaths per 1000 live births in 1995, to 128 deaths per 1000 in 2009 – a remarkable 43% reduction [4]. In preparing child mortality–reduction strategies in the post–2015 era, progress in reducing child deaths around the globe will require new and different strategies from those used to get the world to the current point. For instance, it is important for each country to know not only the magnitude of under–five mortality, but also the biological causes and social determinants of these deaths in order to assess needs and develop programs that will reduce avoidable child deaths more quickly. Thus, reliable direct estimates of the causes and the determinants of under–five deaths are needed to efficiently tailor evidence–based policies and programs. A national verbal/social autopsy (VASA) study was conducted in Niger as part of the Child Health Epidemiology Reference Group’s (CHERG) recent efforts to directly measure the causes and determinants of neonatal and child mortality in selected high–priority countries. The current paper aims to complement the recently published verbal autopsy findings [5] and reports on the social autopsy data of post–neonatal deaths. The objective is to provide insights into modifiable family, household, and health system factors that contributed to the deaths of children (1–59 months) from 2007 to 2010 in Niger, information that will be vital to health policymakers in government and non–governmental organizations as they develop new policies and programs for better resource planning in the post–2015 period.