Improving Civil Registration and Vital Statistics Global Forum on Gender Statistics Rome, December

HMN: what it is and what it does A global partnership whose goal is to increase availability and use of timely, reliable health information in countries and globally through shared agreement on goals and coordinated investments in health information systemsHow? Develop framework and standards for HIS Support countries to implement HMN framework Stimulate dissemination and use of health informationPrinciples: Country ownership and stakeholder involvement Link health and statistical constituencies Harmonization and alignment; Paris Declaration Sustainability; catalytic funding Systems approach to health information

Why measuring cause-of-death data matters To understand pattern of deaths in a population –Cause of death data is the cornerstone of health information –Not enough to know who dies, but also why To guide interventions in public health, to inform policy and planning To evaluate program effectiveness (e.g. AIDS, tuberculosis, malaria, maternal health), needed by –National and sub-national health authorities –International donors For epidemiological research

Civil registration system as a source of Cause of Death data Ideally: all deaths registered with medical certification of cause of death However: Not all deaths are registered Those that are registered, are often without CoD Those that are registered with CoD, may be without medical certification Those that are registered with medical certification of CoD, may be incorrect Those that are registered with medical certification and correct assignment of CoD, may be mis-coded along the reporting flow Evaluation of quality is very important.

MDG indicators in health sector ideally measured through Civil Registration (partly or fully) IndicatorsData supplied from CR Prevalence of underweight children <5 Births Proportion of 1-year-old children immunized against measles Births Proportion of births attended by skilled health personnel Births <5 mortality rateBirths, deaths by age (and sex and causes of deaths) Infant mortality rateBirths, deaths by age (and sex and causes of deaths) Maternal mortality ratioBirths, deaths by age, sex, causes of deaths Death rates associated with malaria Deaths (by age and sex), causes of deaths Death rates associated with tuberculosis Deaths (by age and sex), causes of deaths All indicatorsAccurate data on population size

Number of countries reporting cause-of-death data from their civil registration system to WHO, 2003

Birth vs death registration In general, the proportion of births registered in a country is higher than the proportion of deaths registered, in part this is because incentives for birth registration (e.g. entry to schooling) are more effective than those for death registration, especially in settings where property inheritance is a marginal issue

Alternative to civil registration to generate vital statistics (1) Censuses with questions on fertility and mortality –Representative (in principle) –Useful for estimating fertility, child and adult mortality, potential for estimating maternal deaths –Not continuous (10 years apart), captures deaths prior to the survey Household surveys –For mortality: Two stage process: Identify households with deaths 40 min. Verbal Autopsy interview –Requires a larger sample to capture adult deaths (very wide confidence intervals - not appropriate for measuring trends) Costly (US$2-5 per respondent), also need to consider cost- benefit of adding VA modules

Alternative to civil registration to generate vital statistics (2) Demographic surveillance sites (DSS) –Continuous monitoring –Already in place in many regions (eg, INDEPTH Network) –Relatively cheap (US$0.02 per registration) –Non-representative (sampling, intervention trails, etc.) Sample vital registration system (SRS) –Continuous monitoring –Representative sample –Requires strong commitment and maintenance –Work in two biggest populations: India SRS and China DSP –Preferred alternative to complete VR

Alternative to civil registration to generate vital statistics (3) These approaches can be of immense value in terms of the production of statistics, however they do not bring the legal and human rights benefits associated with civil registration.

Monitoring Vital Events (MoVE) Initiative: Goals Spearhead a global movement for improving the coverage and quality of vital events monitoring in low-income countries: –Develop and test innovative approaches to recording vital events and the identification of strategic options appropriate to diverse country settings. –Generate better data on mortality levels, trends, differentials and causes of death by age and sex and on births –Encourage counting of all vital events or, where this is not possible, the highest feasible level of representativeness of sample of deaths –Enhance the use of mortality data for resource allocation, planning and evaluation –Enhance national capacity to run and maintain their own civil registration systems

Members AMMP/MEASURE Evaluation India SRS/University of Toronto INDEPTH Network University of Queensland Harvard University UNFPA UNICEF UN Statistical Division World Bank WHO (HQ/ROs) Countries (China DSP, Thailand, Ghana, South Africa, etc.)

Products and On-going activities (as of December 2007) Monitoring Vital Events Resource Kit (launched October 2007) Lancet series "Who Counts" (launched October 2007) Standardized Verbal Autopsy tools Development of assessment tool for vital statistics systems Development of guidelines for using VA with census and household surveys Research on innovative approaches at country-level Assistance to countries to improve civil registration

Possible gender-relevant issues in the process of civil registration Differences in completeness and quality of registration between male and female population? If so, what are the barriers to gender-specific registration? How to address this?