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