1. Strengthening Cause-of-death Information in countries through Africa Programme on Accelerated Improvement of Civil Registration and Vital Statistics System (APAI-CRVS) Workshop on the Principles and Recommendations for a Vital Statistics Systems 2-5 December 2014 United Nations Economic Commission for Africa

2. Outline Why Cause-of-death (CoD) matters The state of CoD information in Africa Challenges in the collection of CoD information in Africa Proposed strategies for improvement Regional resources for improvement of CoD information

3. Why Cause-of-death matters “…..One of the best ways to help the living is by counting the dead- Prabat Jha ” Helping the living however, cannot stop at counting the dead. We must proceed to establish who died and what person the died of.

4. Why Cause-of-death matters: 1.Reliable knowledge on the mortality and Cause-of-death (CoD) of a population is critical for policy making and planning. 2.Mortality and CoD data are foundation for health planning, monitoring and evaluation: this includes MDGs and national health plans.

5. Why Causes-of -death matter: cont.. Cause-of- death data from vital records: – Identify emerging diseases and conditions and track changes in the burden of disease in different groups; – Monitor and evaluate health system performance and the impact of policies and programmes; – Guide priorities for intervention programme and allocate and distribute health sector resources – Contribute to health research and the generation of evidence

6. The state of CoD information: “Only around one-third of all the deaths in the world are recorded in civil registries with the cause-of-death information” …(WHO,2012). In Asia and Africa where the largest number of deaths are reported to occur, capturing cause- of-death information remains a big challenge

7. Quality of globally available information on CoD (2000-2008) Source: WHO,2012

8. The state of CoD information in Africa: Source: WHO,2012 South Africa, Egypt, Mauritius and Seychelles are the only countries where nearly all the dead are counted with their respective cause of death information. The remaining countries have such data only for very limited areas or parts of their population

9. The challenge Only a minority of deaths in Africa occur in medical institutions where there is a physician able to issue a medical certificate including CoD Verbal Autopsy (VA) is not an established practice for the derivation of CoD for non-institutional deaths

10. Common challenges in collecting CoD for deaths in health facilities 1.The law: – does not make it mandatory for the medical institutions to record CoD; – does not recognize the use of WHO’s conventional standard in assigning CoD 2.Practice: – CoD not completed using International Form of the Medical Certificate of CoD. – Poor quality of CoD assignment by doctors – No clear business process for flow and compilation of data

11. Common challenges in collecting CoD for deaths outside health facilities – Deaths are not registered – No systematic process is in place for recording and compiling CoD for death outside health facilities – The use of VA in collection of CoD has been limited to a few experimental areas or through special surveys in selected countries

12. Proposed strategies for improving CoD information for institutional deaths 1.Constitute a core team to implement the strategies and plan of action for improvement of CoD information. 2.Review existing death certificates and related forms and modify as required to ensure alignment with international standards 3.Collaborate with hospital administrators and physicians to develop an action plan for the training of physicians in medical certification. 4.Collaborate with universities and medical training institutions to incorporate ICD training in medical curricula

13. Proposed strategies for improving CoD information for non-institutional deaths 1.Decide on the steps to implement verbal autopsy (Recommend use of WHO VA standards, forms and tools) 2.Test the tools and process (from collection to compilation) through pilot studies 3.Based on the results of the pilot and tool testing exercise, re-design the business process 4.Plan and conduct regular training of lay interviewers in verbal autopsy processes 5.May need to start on a sample basis

14. Regional resources for improving CoD: Assessment tool on CoD Objective: The tool is developed to help countries understand their systems –what works and what doesn’t work and to develop country specific strategies for improvement Why Cause-of-death handled separately: (i) Need for increased focus in the area in view of its poor state of performance in most of our countries. (ii) Operations relating to Cause-of -death are unique and different as compared to those followed in the registration of vital events

15. Immediate next steps Develop a clear set of strategies in improvement of causes of death collection and compilation – this may also include a clear action plan for five years Dual approach in the plan Institutional deaths – clear set of action plans Non- institutional deaths – plan for operational research on verbal autopsy to test the full process – two years (only selected countries?) -move to a nationally representative sample – third year onward Develop a regional pool of experts on death registration, causes of death including verbal autopsy who can be assigned to countries on demand

16. Thank you