The impact of primary health care services on under-five mortality in rural Niger

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 modem 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 modem health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal tests 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.