Evaluation of civil registration and vital statistics system in the Maldives: Focus on mortality statistics

1.Introduction

Civil registration and vital statistics (CRVS) systems play an important role in generating data for good governance, measuring health outcomes and monitoring progress of sustainable development goals (SDGs). However, most low- and middle-income countries still have underdeveloped CRVS systems [1]. With a population of around 350 thousand spread across 187 islands [2] efficient implementation of a CRVS system in the Maldives poses a big challenge in terms of timely exchange of information and real-time analysis [3].

The CRVS system in the Maldives was introduced more than 50 years ago. As early as in 1960s, births and deaths were being reported to the Ministry of Health (MoH) through a registration system. This system was not properly enforced until the birth and death registration law was enacted in 1992 [4]. The new law mandated that a burial be permitted only after the death is compulsorily reported and cause(s) of death medically certified by a doctor or medical practitioner. This quickly and drastically improved death registration levels and cause of death reporting in the Maldives.

From 2003 onwards, a triplicate-copy system of reporting births and deaths through the birth form and the death certificate has been operational: the original copy is given to the parent or guardian in case of birth and the next of kin in case of deaths; the second copy is provided to the island administration; and the third copy is transmitted to the Department for National Registration (DNR), which inputs the data in the CRVS database. These forms are then coded in the CVRS database by the MoH [3].

This paper aims to evaluate the completeness and quality of data on death registration and cause(s) of death collected as part of the CRVS system. The CRVS is the single most important source of information on the aforesaid topics. The number of deaths and cause(s) of death as reported on the death certificate [5] are important to assess burden of diseases, the completeness and quality of vital statistics (VS) data [6]. The evaluation is mainly based on analysis of data obtained from the registration records on death and causes of death for the period 2009–2018.

2.Review of literature

Timely, quality, reliable and usable mortality data, trends and causes of death information are important to public health policies and interventions [7, 8]. Information on mortality in the Maldives is presented as the key mortality statistics in annual health statistics reports [9]. As of today, there is no published assessment or study on the CRVS of Maldives, although global estimates [10] show that the quality of VS with regard to completeness and recording of cause(s) of death is low in the Maldives.

Phillips and colleagues, developed in 2014 a procedure to combine six dimensions of VS in a composite Vital Statistics Performance Index (VSPI) [11]. ANACODA [12, 13] uses an adapted version of VSPI with 5 dimensions to assess the quality of death data as a matrix index (VSPI(Q)). The VSPI(Q) does not include data availability/timeliness dimension of the VSPI. The VSPI(Q) as an overall summary index of the quality of the mortality input data, combines the following five components of data quality into one measure [13]: (a) completeness of death registration, (b) amount and type of ‘garbage’ codes used to record the cause of death, including any non-ICD codes, (c) the degree of cause-specific detail included in the input data, (d) the frequency of biologically implausible causes of death in the dataset and (e) the fraction of deaths for which neither age nor sex was recorded.

Due to the complexity and level of engagement by different institutions in the CRVS system, mapping of the vital registration process is useful to capture and identify the bottlenecks, time lags and areas where efficiencies are needed [14]. This in return can improve measurement of health outcomes through targeted investments for process efficiency. However, it must be noted that most of the CRVS systems around the world lacks the long-term public policy investments [15]. Thus, advocates are imperative to improve the CRVS system and work towards a greater political commitment for establishing effective processes and improving of systems [16].

3.Methodology

This study explores data on all the registered deaths from 2009 to 2018 in the CRVS system of the Maldives.

4.Results

4.4Level of cause specific details

The score on ‘Level of cause specific detail available’ mirrors the pattern of the ‘Quality of death reporting’ with a score of about 81, and a small drop in the period 2015–2016 to 79.4 (Table 1). The results show that the change in the top 10 leading causes of death over the ten-year period (2009–2018) is not significant; 6 (for males) and 7 (for females) out of the top 10 causes belong to the garbage (including insufficiently specified) category. The majority of the codes belong to group 2 according to GBD (Table 3).

In conclusion, the quality of death information beyond some minor fluctuations, has not improved over the past 10 years, making the data unusable for policy and programming purposes. Further, the ANACONDA results show that priority intervention areas for improving data quality were ‘Quality of cause of death reporting’ and the ‘Level of cause of specific details’ (Table 1)

Figure 1.

Business process map: Maldives CRVS system. Note: “>” this means “ more than”. BPM developed using Bizagi. Source: Authors findings.

Figure 2.

Business process map: Maldives CRVS system with an online system. Note: Developed using Bizagi. Source: Authors findings.

5.Discussion, conclusion and recommendations

It is widely recognized that a well-functioning CRVS systems and investment into strengthening the system are not only vital for individuals and societies, but also a development imperative that is critical for national health [15]. The Maldives is among the very few countries in the World Health Organisation (WHO) South East Asia Region (SEAR) [22] that has been able to register almost all deaths in its territory with information on causes of death. However, when compared to other small island countries Maldives performs poorer than Mauritius but better than Seychelles [23]. The reporting and quality of age and sex for all registered deaths have consistently been complete over the last ten years. However, the quality of reporting causes of death remains a major concern. Similar to what is reported in global studies [23], there has been little improvement in the VSPI(Q) from 2009 to 2018 in the Maldives. The proportion of garbage codes remains very high with more than half of them in the category of very high severity. This includes a handful of causes such as cardiac arrest, shock and deaths reflected with impossible causes, coded as such as a minor injury. There are only a few ICD codes that contribute to most of the garbage codes; these include cardiac arrest, unspecified, essential (primary) hypertension, other ill-defined and unspecified causes of mortality and septicemia, unspecified, and respiratory arrest. This makes the overall quality of the data poor and of little use to policy makers.

The assessment of death certificates based on the Medical Certification of Cause of Death (MCCOD) tool [24], showed that in addition to illegible hand-writing, there were weaknesses in other aspects of quality cause of death recording [25]. This observation raised questions about whether the current practices to equip doctors with skills for MCCOD are appropriate and adequate. Improving the quality of MCCOD solely rest within the mandate of the MoH in the Maldives and flows downstream to the health care providers. Since the CoD certification is completed by a medical doctor in the Maldives, there is a unique opportunity to improve the quality of CoD data. This can be achieved through training of doctors in standard death certification practices, which has proven to reduce the errors in other countries [26]. This can be supplemented with strategies such as hospital based committees that can oversee cause of death quality assessments [27].

The functions of the CRVS system in the Maldives, as in many other countries, is handled by multiple stakeholders. This arrangement introduces an inherent risk of fragmentation that requires each party to play an important role to improve its functioning. Experiences from other countries show that no single agency can be expected to tackle the weaknesses of CRVS system [28].

The CRVS system in the Maldives is complete from the perspective of the level of registration and the process is fairly well-functioning though there are time delays in transmission of information due to geographic dispersion of population. The country has initiated action for implementing an online CRVS system, which is expected to cut down on the delay in transmission, processing and compilation of mortality data and has the potential to provide mortality data in real-time. It must be, however, recognized that a real-time CRVS system neither automatically improves quality of data nor brings efficiencies in the processes. Efforts must be made to systematically enhance the organizational capabilities such as policies, legal framework, human resources, management and coordination in order to implement a CRVS system that is able to provide data in real time with the desired quality. It would be crucial to systematically assess the current status of death registration and CoD [29] identify bottlenecks and develop, based on analysis, a strategic action plan with indicators for monitoring and timelines for implementation. A significant and sustained government commitment and investment in strengthening the CRVS in the Maldives is recommended in response to monitoring mortalities as mandated by the SDGs [30].