Dr Peter Ebongue Mbondji Regional Adviser

Evidence and Natinal Health Oservatories (ENO) WHO Regional Office for Africa

COIA Sub-Regional Workshop. Harare, Zimbabwe, 01-03 October 2012

UN Commission on Information and Accountability

for Women’s and Children’s Health - 2011

COIA Recommendation 1: Better Information for better results

“Vital events: By 2015, all countries have taken significant steps to establish a system for registration of births, deaths and causes of death, and have well-functioning health information systems that combine data from facilities, administrative sources and surveys”

VITAL EVENTS

Vital events is essentially about

Births, Death and Causes of death.

Vital events data provide key health status indicators

1. Birth : – Adolescent birth rate MDG 5 indicator

2. Mortality: – Under-5 mortality rate (U5MR) – Infant mortality rate (IMR) – Maternal mortality ratio (MMR) – Life expectancy (e0) – Adult mortality rate (45q15) – Neonatal mortality rate (NMR)

3. Causes of Death: – Incidence and death rates associated with malaria – Incidence, prevalence and death rates associated

with tuberculosis

MDG 4 & 5 indicators

MDG 6 indicators

Public health importance of cause of death data

• Monitor the health of the population – Leading causes of death

– Mortality rates (geographic variations)

– Trends over time

• Inform decisions about health policy and strategy – Prevent premature deaths

– Service provision

– Health budgets

• Evaluate health service outcomes

Why vital statistics data are important (1)

• Used to derive demographic and epidemiologic measures needed in national planning in health

• Understanding the – prevalence and distribution of mortality, – emerging health challenges (NCDs, HIV/AIDS, Injuries,…)

• Identification of health inequalities and priorities, • Monitoring of trends and progress towards MDGs • Evaluation of the impact and effectiveness of health

programmes including tracking of health reforms • Complete and Accurate measures of infant, child, and

maternal mortality.

Not only health:

• Education

• Labour

• Other government activities

• Commercial enterprises (e.g. life insurance, marketing of products).

• Tracking national processes such as poverty reduction strategies, and development efforts overall

Why vital statistics data are important (2)

Civil Registration and Vital Statistics (CRVS) System

• Statistics on births and deaths are recorded through the government’s civil registration system Permanent Record (PR) of each event

• Two primary uses of PR:

– Personal legal documents for every citizen

– Basis of the vital statistics system, core of a country’s HIS

CIVIL REGISTRATION RECORDS = Best source for Vital statistics data.

Health sector needs

• Mortality and cause of death data are foundation for health planning, monitoring and evaluation: this includes MDGs, national health plans, evaluation studies

• Levels, trends and differentials (equity) for mortality indicators:

– Mortality rates • key indicators: Neonatal, infant and child mortality, adult mortality, life

expectancy…

– Causes of death, including maternal mortality, infectious diseases, NCD, injuries…

• Disaggregation essential: by age and sex, by cause, by geographic location, socio-economic factors

Current situation CRVS

• Most countries in the region do not have well functioning systems

• Birth registration and death registration levels are low

• There are no/very few vital statistics generated from the civil registration systems

• Cause of death information is not available, or of poor quality (from hospitals but not using ICD) – Many cases of reporting causes of death still have at least

one error!!

Coverage of births and deaths in AFR, 2000-2008

Coverage of deaths in AFR, 2000-2008

Birth and death registration levels are still low

Cause of death information is not available, or of poor quality

Quality of globally available information on causes of death

Mortality data sources

• CRVS: best source if complete and high quality system

• Household surveys and censuses: main source for most countries in the region

– Recent household deaths, birth and sibling histories…

• Hospital data: Reporting of causes of deaths

• Health and demographic surveillance studies: local only

– INDEPTH network, use of verbal autopsy…

Health Sector: A major producer of CRVS data

Health sector produces birth, death and causes of death data through:

1. Hospital reporting

• Complete reporting by hospitals of births and deaths • Causes of death, using the ICD 10

2. Community reporting: CHWs; with electronic devices... Most deaths and births occur at home, outside health facilities

• Community reporting of birth and deaths: first line for reporting

• Verbal autopsy when there is a death

STRENGTHENING THE CRVS SYSTEM:

• Assessment

• Reporting

• Data

• Focus is on births, deaths, causes of death

• Built on global standards developed by UN and WHO

Describes standards against which to assess country CRVS systems

Identify gaps and weaknesses in birth, death and cause-of-death statistics and the system that produces them

Actively involve multisectoral stakeholders

Generate evidence for an improvement strategy

Suggest a roadmap to follow

http://www.uq.edu.au/hishub/theme3

Strengthening CRVS Systems (1): Assessment

A comprehensive, standards-based framework

1. Assessment of current status and practices – Rapid assessment often done

to raise awareness and advocacy for CRVS

– Full assessment forms the basis for a plan

2. National plan for strengthening CRVS

• Developed with all relevant stake holders

• Costing 3. Strong coordination

mechanism 4. Political (and financial)

commitment from the government (can never be donor driven)

Process for reviewing civil registration and vital statistics systems

Process for reviewing civil registration and vital statistics systems

5. Hospital reporting

• Complete reporting by hospitals of births and deaths

• Causes of death using the ICD 10

6. Community reporting

• Most deaths and births occur at home, outside health facilities

• Community reporting of birth and deaths, e.g. CHWs and with electronic devices

• Verbal autopsy if there is a death

Strengthening CRVS Systems (2): Reporting

Immediate cause on top line

Any causal sequence with underlying cause

Contributing cause but not in causal sequence

in Part 2

Attending doctor: • Establish diagnosis • Complete medical certificate of cause (International form –

WHO)

Coding by Statistical Office: • Code causes of death (ICD code for each cause listed) • Classify cause of death (select a single underlying cause of

death for stats according to ICD selection rules) • Check validity, query

Analysis by Statistical Office: • Tabulate and disseminate data

Source: Adapted from Johansson LA, 2008

Main stages in production of cause of death

statistics

Practices affecting the quality of cause-of-death data

• Access to cause-of-death information • Would HIV/AIDS or suicide be assigned to a more socially

acceptable cause of death? • Does the death certificate state whether a woman was

pregnant or had recently been pregnant? Are maternal deaths reviewed separately?

• Are perinatal deaths monitored using a special form that obtains details about the mother as well as the baby?

• What training do doctors receive in COD certification? • Has there been an evaluation of the quality of medical

certification? • Who certifies whether the cause of death is natural or

unnatural? How well does this system work? Are certifying doctors aware of how this system works?

7. Vital statistics • Data quality assessment of birth and death data

is critical as no system will be perfect

• Vital statistics from Civil Registration need to be produced regularly

8. Community reporting • If there is no good CRVS, health and

demographic surveillance sites can be used to obtain intermediate data

• Many countries have such HDSS but the data are not used

Strengthening CRVS Systems (3): Data

Who is involved in CRVS? Government: CR Authority/Dept. National Statistics Office Ministry of Health Ministry Interior Ministry of Local Government Ministry of Justice Min. of Information Ministry of Finance Ministry of Planning Academia Research National Identification Agency

Others:

• Citizens Non-citizens • Civil Society • Community/Tradiotional/Religiou

s Leader • Development Partners • UN Agencies (UNFPA, UNICEF,

WHO, UNDP, UNAIDS, UNHCR) • Developmnet Banks • Private Sector • ICT Companies • Education Sector • The Press and Media Practitioners • Community Workers and

Community voluteers

Interventions

1. Strengthening health information systems:

Better information Better actions to improve quality of care Prevent future deaths...

• Data quality gaps: relevance, accuracy and punctuality

– Quality of death & causes of death statistics • Deaths that occur outside hospital (verbal autopsy , …) • Mortality coding practice

• Harmonization of HIS

2. Develop a framework for integration of CRVS and health systems

Civil registration records Best source for vital statistics data Health sector a major contributor to CRVS systems

Opportunities Initiatives and programmes from WHO and partners:

• Available tools to improve CRVS data:

– A comprehensive, standards-based framework to improve quality of birth, death and cause-of-death information

– WHO verbal autopsy standard, based on ICD10

• MoVE-IT Initiative: Monitoring of Vital Events through Innovation/IT; working with countries to enhance CRVS including innovative reporting systems - HMN/ WHO

• African Health Observatory: WHO platform for assessment, promotion, sharing and use of information, evidence and knowledge for health (http://www.aho.afro.who.int) – National Health Observatories: one-stop shop repository of country

health information and data

National Health Observatory: A key role to Integration of CRVS and health

• Birth, death and causes of death registration and statistics (including data quality gaps) – Provide the most accurate, up-to-date and relevant data

from all sources on one unique national platform

• Monitoring of vital events – Monitoring health status of the population including

progress towards MDGs, by regularly providing trends and situation analyses

– Makes standards and tools available

• Advocacy and accountability – Make translated information openly available to all potential

users/reviewers – Provide an open space for networks and CoPs

Regional Commitments

• UN Commission on Information and Accountability of Women and Children’s Health (COIA) Recommendations

• Statistical Commission for Africa: priority on CRVS

–UNECA: African Programme for Acceleration of Improvement of CRVS (APAI-CRVS)

• African Symposia for Statistical Development (ASSD): CRVS priority (Cape Town, Jan, 2012)

• Recommendations from the 2nd African Conference for Ministers in charge of CRVS (Sept 2012)

10/10/2012 30

Monitoring of vital events using Standards and Tools: Assessment, Quality Control, Mobile Devices

Need for functional Civil Registration - Vital Statistics systems in Countries

Generate Evidence on what works: building upon existing work or systems

CONCLUSION

Perspectives

• Assessment of CRVS

• Plan for strengthening CRVS

• Coordination mechanism

• Commitment

• Hospital reporting

• Community reporting

• Vital Statistics

• Local Studies

Self assessment report and country road map to strengthen CRVS

THANK YOU !

Peter E. MBONDJI: mbondjie@afro.who.int – African Health Observatory (http://www.aho.afro.who.int)

http://www.afro.who.int