1. Using the Mozambique Census to Identify Disparities in Sub-national Mortality and Causes of Death Loraine A. West Population Division U.S. Census Bureau Needs Assessment Conference on Census Analysis in Asia United Nations Population Fund, Bali, Indonesia November 23-25, 2011 1

2. Outline of Presentation Background and Motivation Design and Methods Results Lessons Learned and Policy Relevance 2

3. 3 2010 Population: 22.1 million* 11 Provinces 128 Districts Urban areas concentrated in the south 2007 (Dec. 31) Adult HIV prevalence: 12.5 %** Background *Source: * U.S. Census Bureau, International Data Base, 2010 ** UNAIDS, 2008

4. Need for Accurate and Reliable Mortality Indicators at National and Sub-national Levels Lack of a fully-functioning civil registration system –However, only 6% of children under age 5 had their births registered according to the 2004 Population and Health Survey The Demographic and Health Survey ((DHS)1997, 2003) focus on child mortality and do not provide cause-specific mortality Census (1980, 1997, 2007) captures mortality but not cause-specific mortality Cause-specific death information: –Hospitals –Manhica Demographic Surveillance System (DSS) 4

5. Importance of Mortality Data To guide planning and priority setting for health services To identify emerging health problems To monitor progress of health initiatives To evaluate effectiveness of health programs 5

6. Post-Census Mortality Survey Design and Methods 6

7. Overview of Mozambique Post- Census Mortality Survey Designed to identify causes of death at the national and provincial levels by using SAVVY* tools in conjunction with the 2007 census SAVVY Toolkit was developed by MEASURE Evaluation and the U.S. Census Bureau using PEPFAR core funds and is available online Implemented and led by the National Institute of Statistics and Ministry of Health To our knowledge, first time a mortality survey has been linked to a national census 7 * Sample Vital Registration with Verbal Autopsy http://www.cpc.unc.edu/measure/tools/monitoring-evaluation-systems/savvy

8. Mozambique 2007 Population Census Included a question on household deaths in the previous 12 months –Name, age, and sex of the deceased –For women ages 12-50, asked if the woman was pregnant, or had been pregnant or had an abortion within 42 days of death The census served as a frame for the mortality survey 8

9. Mozambique 2007 Population Census 9

10. Sample Design Stratified census enumeration areas (EAs) by province and then by rural and urban Randomly selected census enumeration areas The census supervisory area corresponding to the selected enumeration area along with an adjoining census supervisory area formed a segment Selected a total of 32 segments for each province, except Nampula and Zambezia provinces with 48 segments each 10

11. Deaths in Sample All households in the sample reporting a death in the last year on the census questionnaire were followed up with a verbal autopsy interview. World Health Organization international standardized verbal autopsy questionnaires: –Less than 28 days old –28 days to 14 years old –15 years and older 11

12. Post-Census Mortality Survey Fieldwork Verbal autopsy fieldwork began 2 months after the conclusion of census fieldwork Interviewer located appropriate respondent Forms returned to the capital (Maputo City) for processing and data entry Duration of verbal autopsy fieldwork about 8 months 12

13. Assignment of Cause of Death Twenty-two physicians trained in ICD-10* coding Two doctors independently coded causes of death Discrepancies required doctors to come to agreement or bring in a third doctor Training and assignment of cause of death completed in less than 2 months Cause of death coded for just over 10,000 deaths 13 *Tenth Revision of the International Classification of Diseases

14. Analytical Results from the Post-Census Mortality Survey 14

15. 15 95% Confidence Intervals Represented

16. 16 Source: Mozambique Post-Census Mortality Survey

17. 17 Source: Mozambique Post-Census Mortality Survey

18. 18

19. Percentage of All Deaths that were HIV/AIDS Deaths, by Province: 2006-2007 Source: Mozambique Post-Census Mortality Survey Republic of Mozambique 19

20. 20 Source: Mozambique 2007 Population Census

21. 21 Source: Mozambique Post-Census Mortality Survey

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24. Lessons Learned and Policy Relevance 24

25. Lessons Learned A high quality census is essential; errors in the census, in terms of cartography or data collection, make it difficult to reinterview households for the verbal autopsy Post-census mortality surveys are highly dependent on the census timetable for fieldwork and analysis –Fieldwork could not commence until census forms had returned to the capital for processing – want to minimize the recall period –Mortality rates cannot be calculated until census processing is completed 25

26. Lessons Learned (continued) Multistage structure of the survey creates data management challenges – a unique identifier was generated for each death to link the multiple files Verbal autopsy interviewers determined that nearly 1 in 4 census-reported deaths actually occurred outside the reference period of the previous 12 months, causing a significant decrease in sample size Some stillbirths miscoded as infant deaths in the census 26

27. What was Gained from the Post- Census Mortality Survey Detailed mortality data set based on more than 10,000 deaths –Representative at the national, urban/rural, and provincial levels Mortality rates by age and sex Leading causes of death by age and sex Utilization of health services and place of death Sample is a building block for an ongoing mortality surveillance system 27

28. Policy Relevance of Survey Results Provide national mortality estimates for Ministry of Health budgeting and planning –Serve as a baseline for measuring the impact of scaled-up initiatives that aim to reduce mortality –Identify target populations and/or areas Provide indicators for national initiatives ( e.g., The President’s Malaria Initiative; PEPFAR) and international initiatives (e.g., UNAIDS; the Global Fund to Fight AIDS, TB and Malaria; and Poverty Reduction Strategies Indicators) 28

29. Policy and Program Impact Expansion of anti-retroviral therapy to all provinces Pedestrian safety campaign targeting school children Training of medical personnel in the production of high quality death certificates 29

30. The Way Forward Historically, Mozambique censuses occur once every 10 years – post-census mortality survey provides a snapshot Can use the nationally representative post-census mortality survey sample to establish ongoing surveillance using the complete SAVVY system Ongoing surveillance further builds capacity, with the ultimate goal being a fully functioning vital registration system 30

31. Capacity Building in Data Analysis Demographic Analysis –Fertility –Mortality –Migration Population Estimates and Projections National and sub-national Sub-national Socioeconomic Indicators 31

32. Thank you! Loraine.a.west@census.gov 301-763-6242 This presentation is released to inform interested parties of ongoing research and to encourage discussion of work in progress. Any views expressed on statistical or methodological issues are those of the author and not necessarily those of the U.S. Census Bureau. 32