1. Health records and the role of the health sector

2. Changing role of the health sector
World Health Organization
Changing role of the health sector
7 December 2018
Health sector focused largely on cause of death. Key CRVS agents were Registrar General, Ministry of Interior or Justice, and National Statistics Office.
Countries such as Ethiopia and Rwanda using health workers as active agents in nascent CRVS systems
More active health sector role driven by:
Demand for better statistics on MDGs, mortality in adults;
Increasing proportion of births and deaths taking place in health;
Use of electronic medical records which require unique identifiers;
Growing reach of ICT, such as mobile phones.

4. Legal framework and procedures for notification and registration
Definitions of live birth and fetal death, aligned with ICD standards
Registration of deaths in newly born infants as both births and deaths.
Health facilities must report all births and deaths. Include private, NGO, and social insurance providers.
Death certificate should include checkbox on pregnancy status of deceased woman of reproductive age. Deaths in women of reproductive age investigated to identify maternal deaths.

5. Legal framework and procedures for notification and registration
Specify the official documentation needed for burial or cremation
Specify who can certify death and cause of death; medical certification by trained physicians.
Use international form of the death certificate with deaths ICD-compliant certified and coded.
Specify legal and procedural processes for accidental deaths (e.g. reporting to a coroner).

6. Procedures and practices
Rules and procedures stipulated for each step – notification, registration and certification.
Birth form should include attachment for medical details about the birth, health of baby and mother. Use for record linking to identify infant and maternal deaths.
Rules and procedures should be described separately for events outside of hospitals and for those that occur within hospitals (both public and private).
For vital events outside health facilities explore use of using community health workers to report vital events to the local civil registration authorities.

7. Cause of death
Certification – physician assigns cause of death using the ICD form (which should be filled in its entirety).
Coding – assigning cause of death on the medical certificate to one of the specific ICD codes. This permits the cause of death information on the certificate to be translated into statistical categories and subsequently tabulated for dissemination and use.
Important that the public health value of such data is well understood and there are regulations and procedures to ensure proper certification and coding.
Address social and legal constraints to correct certification. Ensure confidentiality and privacy.

8. Sudden deaths
In cases of sudden death, physician should assess whether death due to natural or external causes (accident, suicide, homicide).
Unnatural deaths referred to enquiry by coroner or special medical examiner to conduct investigation into the circumstances.
Cause of death may initially be registered as unknown pending outcome of the investigation. This can lead to delays in finalizing the data.

9. Coding
Coding should be done by clinical coders and statistical assistants with in-depth knowledge of ICD rules and procedures.
Coding by physicians who certify cause of death not appropriate; they lack detailed knowledge of ICD and not the best use of medical skills.
Centralized coding in MOH or NSO ensures common standards and helps error detection and correction.
Decentralized coding in hospital makes it easier to access records and encourages local use of the data.
Automated systems facilitate correct coding for most deaths but specialist coders needed for complex and external causes

10. Deaths outside medical settings
Village leader or local registrar provides a lay opinion about the cause of death.
Non-medically certified data on causes of death are of little value either at the individual level, for legal purposes, or at the population level, for public health purposes.
In statistical analyses these data should never be combined with cause-of-death data that are medically certified.

11. Verbal autopsy
Where deaths occur outside medical facilities, verbal autopsy can used to determine cause of death.
Verbal autopsy is designed to obtain information on cause of death at the population level, not to legally assign cause of death at the individual level.
Uses standardised questionnaire to ask caregivers, friends or family about signs and symptoms experienced by the deceased person before death..
Cause of death traditionally assigned by doctors. New computer- assisted statistical tools automate cause assignment more cost- effectively

12. Data quality evaluation
Data evaluation and critical assessment integral to all vital statistics systems but often neglected.
Completeness evaluated directly by monitoring statistical returns and identifying gaps or discrepancies. Delayed registration indicative of under-reporting. Direct and indirect demographic techniques.
Plausibility and consistency checks should be performed on cause of death data to assess how robust and credible the data are, and for what purpose they can be used.

13. Conclusions
Ministries of health have widespread network of health care facilities, including hospitals, health centres, and health posts, and outreach clinics.
This stable, complex and functional network provides a mechanism for reaching individuals and families in the community.
The health sector is a major user of vital events data for health programme planning, monitoring and evaluation. It is also increasingly contributing to the collection of birth and death data through health care facilities.