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BackgroundLittle is known about the contribution of community health posts and community health workers (CHWs) to geographical accessibility of primary healthcare (PHC) services at community level and strategies for optimising geographical accessibility to these services.MethodsUsing a complete georeferenced census of community health posts and CHWs in Niger and other high-resolution spatial datasets, we modelled travel times to community health posts and CHWs between 2000 and 2013, accounting for training, commodities and maximum population capacity. We estimated additional CHWs needed to optimise geographical accessibility of the population beyond the reach of the existing community health post network. We assessed the efficiency of geographical targeting of the existing community health post network compared with networks designed to optimise geographical targeting of the estimated population, under-5 deaths and Plasmodium falciparum malaria cases.ResultsThe per cent of the population within 60-minute walking to the nearest community health post with a CHW increased from 0.0% to 17.5% between 2000 and 2013. An estimated 10.4 million people (58.5%) remained beyond a 60-minute catchment of community health posts. Optimal deployment of 7741 additional CHWs could increase geographical coverage from 41.5% to 82.9%. Geographical targeting of the existing community health post network was inefficient but optimised networks could improve efficiency by 32.3%–47.1%, depending on targeting metric.InterpretationsWe provide the first estimates of geographical accessibility to community health posts and CHWs at national scale in Niger, highlighting improvements between 2000 and 2013, geographies where gaps remained and approaches for optimising geographical accessibility to PHC services at community level.

BackgroundLittle is known about the geography of community health workers (CHWs), their contribution to geographical accessibility of primary health care (PHC) services, and strategies for optimizing efficiency of CHW deployment in the context of universal health coverage (UHC). MethodsUsing a complete georeferenced census of front-line health facilities and CHWs in Niger and other high resolution spatial datasets, we modelled travel times to front-line health facilities and CHWs between 2000-2013, accounting for training, essential commodities, and maximum population capacity. We estimated additional CHWs needed to maximize geographical accessibility of the population beyond the reach of existing front-line health facilities and CHWs. We assessed the efficiency of geographical targeting of the existing CHW network compared to modelled CHW networks designed to optimize geographical targeting of the estimated population, under-five deaths, and plasmodium falciparum malaria cases. ResultsThe percent of the population within 60 minutes walking to the nearest CHW increased from 0{middle dot}0% to 17{middle dot}5% between 2000-2013, with 15{middle dot}5% within 60 minutes walking to the nearest CHW trained on integrated community case management (iCCM) - making PHC services and iCCM, specifically, geographically accessible for an estimated 2{middle dot}3 million and 2{middle dot}0 million additional people, respectively. An estimated 10{middle dot}4 million people (59{middle dot}0%) remained beyond a 60-minute catchment of front-line health facilities and CHWs. Optimal deployment of 8064 additional CHWs could increase geographic coverage of the estimated total population from 41{middle dot}5% to 73{middle dot}6%. Geographical targeting of the existing CHW network was inefficient but optimized CHW networks could improve efficiency by 55{middle dot}0%-81{middle dot}9%, depending on targeting metric. InterpretationsWe provide the first high-resolution maps and estimates of geographical accessibility to CHWs at national scale, highlighting improvements between 2000-2013 in Niger, geographies where gaps remained, approaches for improving targeting, and the importance of putting CHWs on the map to inform planning in the context of UHC. O_TEXTBOXKEY QUESTIONSO_ST_ABSWhat is already known?C_ST_ABSO_LIPrevious studies have estimated geographical accessibility (as travel time) to CHWs for subnational areas only1-4 and have assessed efficiency of the distribution of hospitals in low and middle-income countries.5 C_LI What are the new findings?O_LIThe percent of the population within 60 minutes walking to the nearest CHW increased from 0{middle dot}0% to 17{middle dot}5% between 2000-2013, with 15{middle dot}5% within 60 minutes walking to the nearest CHW trained on integrated community case management (iCCM) - making PHC services and iCCM, specifically, geographically accessible for an estimated 2{middle dot}3 million and 2{middle dot}0 million additional people, respectively. C_LIO_LIAn estimated 10{middle dot}4 million people (59{middle dot}0%) remained beyond a 60-minute catchment of front-line health facilities and CHWs in 2013, with important variation across subnational geographies, training of CHWs, and availability of essential commodities. C_LIO_LIOptimal deployment of 8064 additional CHWs could increase geographic coverage of the estimated total population from 41{middle dot}5% to 73{middle dot}6%, providing physical access to PHC services for an additional 5{middle dot}7 million people not covered in 2013. C_LIO_LIOptimized CHW networks increased efficiency of geographical targeting compared to the existing CHW network by 55{middle dot}0%-81{middle dot}9%, depending on targeting metric. C_LI What do the new findings imply?O_LIGeographical accessibility to primary health care services, including iCCM, improved in Niger between 2000-2013 with important contributions by CHWs. C_LIO_LIGaps in geographical accessibility remained as of 2013 but scale-up of the CHW network, using the scale-up approach described in this study, could substantially increase geographical accessibility of PHC services. C_LIO_LIThe efficiency of geographical targeting of the existing network of CHWs was suboptimal. The approach for optimizing efficiency of geographical targeting described in this study could be used to improve geographical targeting of CHW deployment in Niger and other countries. C_LIO_LIThis work is a first step toward establishing a geography of CHWs in Niger and is a call to action to put CHWs on the map globally to inform health system planning and maximize geographical accessibility, efficiency, and impact of investments in the context of UHC. C_LI C_TEXTBOX

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.

Niger, one of the poorest countries in the world, recently used for the first time the integrated verbal and social autopsy (VASA) tool to assess the biological causes and social and health system determinants of neonatal and child deaths. These notes summarize the Nigerien experience in the use of this new tool, the steps taken for high level engagement of the Niger government and stakeholders for the wide dissemination of the study results and their use to support policy development and maternal, neonatal and child health programming in the country. The experience in Niger reflects lessons learned by other developing countries in strengthening the use of data for evidence–based decision making, and highlights the need for the global health community to provide continued support to country data initiatives, including the collection, analysis, interpretation and utilization of high quality data for the development of targeted, highly effective interventions. In Niger, this is supporting the country’s progress toward achieving Millennium Development Goal 4. A follow–up VASA study is being planned and the tool is being integrated into the National Health Management Information System. VASA studies have now been completed or are under way in additional sub–Saharan African countries, in each through the same collaborative process used in Niger to bring together health policy makers, program planners and development partners.

The 2010 Niger National Mortality Survey (NNMS) found that from 1998 to 2009 the mortality rate of children less than 5 years old decreased significantly by 43.4%, from 226 (95% confidence interval CI 207–246) to 128 (95% CI 117–140) deaths per 1000 live births, but mortality of neonates less than 28 days old declined insignificantly from 39 (95% CI 32–46) to 33 (95% CI 28–39) deaths per 1000 live births [1,2]. The reduction in child deaths was attributed to improvements in the nutritional status of children less than 2 years old and increased coverage of key child survival interventions, including insecticide–treated bed nets, vitamin A supplementation, treatment of diarrhea with oral rehydration salts and zinc, careseeking for childhood pneumonia and fever or cough, and vaccinations. The rapid uptake of interventions was achieved through government policy decisions to implement the Integrated Management of Childhood Illness (IMCI) approach, integrated community case management for children with fever or malaria, suspected pneumonia and diarrhea, and to provide free health care for all pregnant women and children including scaling up access to a minimum package of high–impact interventions at integrated health centers and health posts. Interventions effective against neonatal mortality that were examined, including antenatal care, maternal tetanus toxoid, skilled birth attendance, early initiation of and exclusive breastfeeding, showed smaller increases in coverage to endpoint levels well below 50%, likely inadequate to decrease neonatal mortality [1]. In addition, an earlier study on the quality of maternal and newborn care found that few health workers present at birth had the knowledge, skills and access to basic equipment needed to effectively manage obstetric and newborn problems. Only 2.5% of Centres de Sante Integres (CSI), which are meant to have at least two nurses or midwives on duty at all times and which are the main health centers throughout the country intended to provide Basic Emergency Obstetric and Neonatal Care (BEmONC), had the full capacity for this service; and the national met need for EmONC stood at 2.3%, varying by region from 1.4% to 6.5% [3]. Health posts (Case de Santes), only about one–fourth of which have a nurse or midwife on staff and are not intended to provide EmONC, were not examined. Neither of these studies, however, examined several other interventions critical to neonatal survival nor did they assess the causes of and events leading up to the deaths of the newborns along the continuum of antenatal and delivery care of the mother and immediate postnatal care of the newborn, maternal complications and the severe newborn illnesses these can lead to, mothers’ perceptions and knowledge of how to respond to such critical events, their careseeking attempts for themselves and their newborns, and factors affecting these behaviors. The fact that maternal complications occur at a fairly constant level, severe enough to kill the mother in about 1.0% to 1.4% of pregnancies and to kill the baby at a much higher rate, and that it cannot be reliably predicted which women will experience these complications, is the basis for the maternal mortality reduction strategy of universal access to skilled birth attendance and emergency obstetric care when needed [4–7]. This strategy is no less important to the survival and health of the neonate, as it has been shown that pregnancy and delivery complications are the most important risk factors for neonatal mortality [8–12], with care directed at the intrapartum period providing the greatest mortality reduction [13]. Integrated maternal–neonatal care packages and linkages of community with facility maternal and newborn care provide further reductions in stillbirths and neonatal deaths [14,15]. The addition of newborn–specific strategies, including fetal monitoring, access to Caesarean section for fetal distress, clean delivery and cord care, neonatal resuscitation, early initiation of and exclusive breastfeeding, timely and appropriate thermal care of the baby, kangaroo mother care for stabilized preterm infants, recognition of and early careseeking for newborn illness, access to quality health care, and urgent referral to neonatal intensive care when needed, are required to maximize newborn survival [13,16–20]. Examining such vital information on maternal and newborn care provided for babies that died is needed to help explain why the deaths occurred and how they might have been prevented. Collecting comparison data for newborns that suffered a severe but non–fatal illness during the same time period as the deaths would require the difficult task of identifying households where such an illness occurred; and the inability to appropriately match deaths with other cases on the basis of illness severity and the timing of clinical signs has led to a misleading situation where one could falsely conclude that treatment increased mortality risk [21]. Moreover, promoting neonatal health and preventing the death of sick newborns requires well–proven interventions for which the population levels established by already–completed surveys can provide reasonable comparisons for the surveyed factors. Social autopsy (SA) is a method of inquiring about deaths that adds questions on household, community and health system determinants of mortality to complement a verbal autopsy (VA) interview on the illness signs and symptoms used to establish the biological cause of death [22]. We undertook to assess the biological causes and social determinants of recent neonatal deaths in Niger by conducting a verbal/social autopsy (VASA) study of neonatal deaths that occurred in 2007–2010 and were identified by the 2010 NNMS. Where possible, we compared the VASA findings for the deaths to the same factors for surviving children from the same cohort determined by recent population surveys. In this way, we sought to further explain the reasons for the limited decrease in neonatal mortality in Niger from 2007 to 2010.

Summary Background The Millennium Development Goal 4 (MDG 4) is to reduce by two-thirds the mortality rate of children younger than 5 years, between 1990 and 2015. The 2012 Countdown profile shows that Niger has achieved far greater reductions in child mortality and gains in coverage for interventions in child survival than neighbouring countries in west Africa. Countdown therefore invited Niger to do an in-depth analysis of their child survival programme between 1998 and 2009. Methods We developed new estimates of child and neonatal mortality for 1998–2009 using a 2010 household survey. We recalculated coverage indicators using eight nationally-representative surveys for that period, and documented maternal, newborn, and child health programmes and policies since 1995. We used the Lives Saved Tool (LiST) to estimate the child lives saved in 2009. Findings The mortality rate in children younger than 5 years declined significantly from 226 deaths per 1000 livebirths (95% CI 207–246) in 1998 to 128 deaths (117–140) in 2009, an annual rate of decline of 5·1%. Stunting prevalence decreased slightly in children aged 24–35 months, and wasting declined by about 50% with the largest decreases in children younger than 2 years. Coverage increased greatly for most child survival interventions in this period. Results from LiST show that about 59 000 lives were saved in children younger than 5 years in 2009, attributable to the introduction of insecticide-treated bednets (25%); improvements in nutritional status (19%); vitamin A supplementation (9%); treatment of diarrhoea with oral rehydration salts and zinc, and careseeking for fever, malaria, or childhood pneumonia (22%); and vaccinations (11%). Interpretation Government policies supporting universal access, provision of free health care for pregnant women and children, and decentralised nutrition programmes permitted Niger to decrease child mortality at a pace that exceeds that needed to meet the MDG 4. Funding Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Canada, Norway, Sweden, and the UK; and UNICEF.

UNICEF commissioned a qualitative evaluation of a program in which two partners conducted prevention activities concerning HIV/AIDS and STIs amongst youth in Madagascar. The evaluation assessed project activities and conducted a practical exercise in focus group methodology, following a workshop on evaluation techniques. Information was collected from a wide range of people, including 441 participants in 46 focus groups in nine sites. Six sites were areas of project activities and three sites were targeted for future activities. Clubs that integrated HIV/AIDS and STI information into their regular activities were most successful in their information, education and communication activities. A more participatory approach is recommended, to achieve a better match between target groups and messages delivered, and to foster trust and support. Another challenge remaining is to address fears and stigma through advocacy for the care and support of affected people.