Background: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period.
Methods: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects.
Results: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources.
Conclusions: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.
PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.