|Year : 2019 | Volume
| Issue : 3 | Page : 163-164
Mortality surveillance in India: Past, present, and future
Anand Krishnan1, Dilip Kumar Das2
1 Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
2 Editor, Indian Journal of Public Health, Professor, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
|Date of Web Publication||20-Sep-2019|
Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnan A, Das DK. Mortality surveillance in India: Past, present, and future. Indian J Public Health 2019;63:163-4
While debates in the media about India's Gross Domestic Product story are quite common, debates on India's Crude Death Rate and causes of death are rare. Perhaps the “wealth” of a nation is more important than the “health” of a nation. Lack of public awareness on issues related to death reporting also contributes to this low visibility. One can bet that most Indians would not know the major causes of death in India. Most health professionals do not know the process of mortality data collection in India other than medical certification. Our experience shows that even postgraduate students in community medicine are not fully conversant with India's mortality surveillance system.
Mortality surveillance has two components – the first is to count all the deaths and the second is to ascertain the cause of death in all of them or a representative subsample. Deaths in India are registered either under the mandatory reporting of births and deaths to the registrar of births and deaths by their next of kin or by hospitals, under the Civil Registration System (CRS). In addition, deaths in villages are reported by Gram Sewaks/Gram Panchayat Members through the Panchayati Raj system. As per the annual report of CRS for 2015, the number of registered deaths reached 6.27 million in 2015 as against an estimated 8.25 million deaths (an estimated three-fourths of all deaths) with 40% being institutional. The Sample Registration System (SRS) was started in 1969 as an admission of impossibility of counting all the births and deaths. As the name indicates, under this system, we cover a “representative sample” of India that is spread over all the states wherein an active surveillance for demographic events – births and deaths – are conducted on a continuous basis. This generates birth and death rates for all states and the country on an annual basis. Despite starting as a temporary measure, it has continued for about half a century as we are still far from achieving universal birth and death registration.
Ascertaining cause of death is much more complex. “Lay Reporting of Cause of Death” as reported at the time of registration by the next of kin is of questionable validity., Hospital deaths are certified by a doctor, and the certificate is sent to the Municipality or District Registrar of Deaths under the system known as medical certification of causes of death (MCCD). There are a couple of limitations with the MCCD system. The first is coverage. Majority of deaths in India do not take place at hospitals; especially in rural and tribal areas. As per the report released by the Office of the Registrar General of India (ORGI) in 2015, 1.2 million deaths were medically certified. This constitutes only about 20% of the reported deaths and 14% of all deaths. Moreover, states such as Uttar Pradesh, Haryana, and Jammu and Kashmir did not report any deaths at all under this scheme thereby leading to regional disparity. The other challenge rests with the quality of certification by doctors. It has been well-documented that doctors do not correctly record cause of death. Common causes reported are cardiac arrest or respiratory failure, which are mechanisms of dying and not the underlying cause. This is because doctors do not understand the importance of correctly recording this information nor are they trained properly for it, as it is not the job of any specific department. Filling of the death certificate is delegated to the lowest rung, often trainee interns. No wonder, certification is done poorly!
There are many ongoing initiatives to strengthen medical certification of deaths in India. (https://sjri.res.in/announcement/Online Course on_ Medical Certification_of_Cause_of_Death__MCCD; http://www.ncdirindia.org/e-mor/).
Until December 1998, cause of death data for rural areas used to be collected under the Survey of Cause of Death Rural scheme, from a sample of villages by lay diagnosis and reporting system. From January 1999, a cause of death component was merged with the SRS. After an initial pilot, in 2001, the Government of India initiated a process of doing verbal autopsy (VA) of about 45,000 deaths (0.5% of all annual deaths) identified under SRS every year. This was done with technical support from the Centre for Global Health Research (CGHR), University of Toronto. A memorandum of understanding (MoU) was signed with the ORGI to cover about 1 million estimated deaths till 2014 and this initiative was named the “Million Death Study.” This resulted in the availability of mortality estimates for India which also contributed to national and global disease burden estimates. Unquestionably, these estimates also promoted evidence-based policy decisions, including a better appreciation of Non Communicable Diseases (NCDs) as a major contributor for deaths and disabilities. This is not to say that the SRS system does not have its faults. While VA-based systems are globally accepted, there continue to be concerned about some disease estimates based on them. This is best illustrated by the estimate for deaths due to malaria by the CGHR team which was strongly contested by the Indian officials and WHO.,, This controversy also resulted in increasing concern on India's mortality data being managed by an international agency. This is in keeping with a global concern about data privacy and protection and a movement toward safeguarding national data. Other concerns with the existing system are the 5–6 years delay in the release of reports and the shrinking number of deaths within the existing sampling units due to declining mortality rates. This impacts the ability and precision of the system to generate state-level estimates and estimation of maternal mortality.
These concerns resulted in ORGI initiating a process of identification of a national technical partner, which finally ended with the selection of the All India Institute of Medical Sciences (AIIMS), New Delhi. Subsequently, AIIMS established a Technical Support Unit to improve and facilitate the process of VAs for deaths recorded under SRS. This support extends to all facets of the process, including revision and standardization of data collection instruments, training of census supervisors, part-time enumerators in the conduct of VA, streamlining the data collection, transmission and analysis of data as well as enrolling and training an adequate number of doctors for assigning cause of death based on reading of the VA form. Recognizing the scale of the task and the need to have nationwide and multilingual representation, AIIMS, New Delhi, along with other medical colleges/institutes in states setup the Mortality in INdia Established through Verbal Autopsies (MINErVA) network. As of August 2019, departments of community medicine of 25 reputed government and private medical colleges from across the country are part of the MINErVA network and have together enrolled 804 physician coders. The MINErVA Technical Advisory Group consists of public health experts, clinicians, social scientists, statisticians, and nominees from ORGI, Ministry of Health and Family Welfare, WHO, and the Indian Council of Medical Research. The involvement of the departments of community medicine of the network partner institutions will be mutually beneficial and strengthen the departments as well. Two online IT platforms have been created as a part of the network – a training platform (http://causeofdeathindia.com) which is in public domain meant for training of physicians in ascertaining cause of death from VAs and a coding platform (http://minervacoding.aiims.edu) which is for network members to code deaths identified under SRS based on the VA forms.
The MINErVA network will work to strengthen the mortality surveillance system in India by ensuring timeliness of data collection and availability, improving the quality of VA, and its coding by leveraging information technology in the process of data collection and coding. This development also means that the system has moved from a “study” to a “surveillance” mode. Surveillance is an essential national public health function and indigenization of the system augurs well for its future sustainability. However, the ultimate purpose of surveillance is the use of data for policies and programs.
India has committed itself to Sustainable Development Goals which have specific targets for deaths in specific age groups (infant and neonatal), pregnancy-related deaths, and deaths due to specific diseases such as NCDs, tuberculosis, or malaria. Having a robust mortality surveillance system is not a luxury but an essential prerequisite for any country that is interested in improving the health of its citizens. However, the Ministry of Health presently does not have an adequate stake in the current mortality surveillance system despite being its prime user. An effective mechanism needs to be put in place for better harmonization between the Ministries of Health and Home Affairs. In the long term, we should integrate civil registration with the primary health-care system and conduct VAs on all nonhospital deaths. This has a great transformative potential in making mortality indicators useful for monitoring the health of the nation.
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