Elsevier

The Lancet

Volume 370, Issue 9600, 17–23 November 2007, Pages 1726-1735
The Lancet

Series
Interim measures for meeting needs for health sector data: births, deaths, and causes of death

https://doi.org/10.1016/S0140-6736(07)61309-9Get rights and content

Summary

Most developing countries do not have fully effective civil registration systems to provide necessary information about population health. Interim approaches—both innovative strategies for collection of data, and methods of assessment or estimation of these data—to fill the resulting information gaps have been developed and refined over the past four decades. To respond to the needs for data for births, deaths, and causes of death, data collection systems such as population censuses, sample vital registration systems, demographic surveillance sites, and internationally-coordinated sample survey programmes in combination with enhanced methods of assessment and analysis have been successfully implemented to complement civil registration systems. Methods of assessment and analysis of incomplete information or indirect indicators have also been improved, as have approaches to ascertainment of cause of death by verbal autopsy, disease modelling, and other strategies. Our knowledge of demography and descriptive epidemiology of populations in developing countries has been greatly increased by the widespread use of these interim approaches; although gaps remain, particularly for adult mortality. However, these approaches should not be regarded as substitutes for complete civil registration but rather as complements, essential parts of any fully comprehensive health information system. International organisations, national governments, and academia all have responsibilities in ensuring that data continue to be collected and that methods continue to be improved.

Introduction

Accurate and timely data for mortality by age, sex, and cause both nationally and subnationally are essential for the design, implementation, monitoring, and assessment of health programmes and policies.1 In countries with well developed statistical systems, the necessary information for such descriptive epidemiology is derived from civil registration, medically certified cause of death, and population counts from regular censuses or population registers. However, the paper by Mahapatra and colleagues2 in this Series has convincingly shown that these data are simply not available for many countries with poorly developed statistical systems: in these countries births and deaths might not be registered completely; for those deaths that are recorded, the age at death might be misreported; the cause of death might not be certified by a physician; it might be recorded as an ill-defined cause; and could be misdiagnosed. Population numbers, needed as denominators, can suffer from errors of coverage and errors in reporting the age of individuals. These failures derive from technical and structural weaknesses, ranging from bureaucratic inefficiency and poor management of data to having inadequate incentives, or even disincentives for the population to record vital events.

Both national governments and the international community should give high priority to policies that will upgrade civil registration systems so that all countries will enjoy the benefit of a solid empirical base for health-sector planning. However, experience has shown that such improvements cannot be achieved overnight and need investment not only in administrative systems but also in public awareness.3 The number of countries with death registration regarded as complete (by the not very rigorous standard of 90%) increased by only seven from the 1970s to the 1990s.3 Interim substitutes for civil registration are needed to provide national and subnational estimates of vital events and cause-specific mortality until achievement of complete civil registration with adequate certification of cause of death by a qualified medical practitioner familiar with the principles and procedures of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). The purpose of this paper is to review the strengths and weaknesses of interim strategies for collection and analysis of data that have been developed as substitutes for complete civil registration. We also highlight how such interim measures are inadequate, and suggest targets for future development.

Key messages

  • The complete registration of births and deaths with accurate ascertainment of cause of death—products of a fully functional civil registration system, and an essential component of any health information system—is inadequate in many developing countries

  • Interim measures developed over the past four decades have been reasonably adequate substitutes in countries without a fully functional civil registration system, with exception of the assessment of causes of deaths

  • These measures, consisting of innovative strategies both for obtaining data and for methods of assessment and analysis, should not, however, be viewed as long-term alternatives to civil registration, but rather as being complementary to such systems

  • International agencies should maintain their support for coordinated data collection and sharing activities and for specialised training, while increasing efforts to achieve a fully functional civil registration system

  • More intensive and better funded research programmes than we have at present are urgently needed to improve and refine the methods of analysis for converting incomplete or indirect information about mortality and causes of death into valid measures of population health for policymaking and planning

Section snippets

Interim substitutes

Several strategies for collection and analysis of data have been developed as interim substitutes for complete civil registration, each with its own strengths and weaknesses. Table 1 summarises the potential contributions of different strategies, and figure 1 shows where some of the strategies (eg, targeted questions in population censuses, sample registration systems, demographic surveillance sites, and household surveys) have been used around the world. These sources of data generally have to

Potential uses of incomplete data

Although civil registration systems in developing countries frequently fail to record all events, incomplete data that are available can still be used (although it is often not tabulated because of concerns about quality). We have discussed above the analytic methods for assessing the completeness of registration of adult deaths; if reporting is complete enough for the recorded deaths to be plausibly representative of all deaths in terms of age distribution (Preston41 suggests a minimum level

Modelling

Models of age patterns of mortality have a long history. The potential value of such models rests on the empirical observation that human mortality systematically varies with age: it is high in infancy, drops to a minimum around age 10 years, and then increases exponentially with age. This regular pattern has given rise to the development of many model life-table systems, mostly on the basis of the historical experience of countries that now have low mortality.5, 44, 45 One contemporary problem

Complementary methods for obtaining data

The discussion of interim measures should not be interpreted to mean that a fully developed health information system can rely exclusively on civil registration data combined with denominators from censuses or population registers. Such data provide an essential basis for descriptive epidemiology, but need supplementation for in-depth analyses and also need periodic validation.

A particular shortcoming of civil registration data is the absence of good socioeconomic information. Linking of death

What interim methods cannot do

Inevitably, interim solutions described here cannot fulfil all functions. By their nature, interim approaches generally rely on retrospective reports of events; they are thus prone to selection bias. For example, both full and summary birth histories exclude births and deaths of children of women who have died. Any strong association between the risk of death of the child and that of the mother will bias estimates of child mortality and distort associations with predictor variables. Similarly,

Conclusions and recommendations

The interim methods for estimation of vital statistics discussed here have largely been developed in the past four decades as cost-effective alternatives for deriving demographic estimates in the absence of civil registration. Substantial progress with these methods means that we now know much more than before about the demography and descriptive epidemiology of populations across the world. Necessity has truly been the mother of invention for this subject, since much of this achievement has

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