1. United Nations Expert Group Meeting on International Standards for Civil Registration and Vital Statistics Systems Session 1.7 Use of health services records for vital statistics 28 June 2011 United Nation North Lawn Building, New York City Boonchai Kijsanayotin MD., PhD. Health Systems Research Institute, Thailand Using health care service administrative data to improve national vital statistics: Thailand experiences

2. Outline  Thailand Civil Registration System  Thailand Vital statistics System  Health care service administrative data  Using administrative data to improve vital statistics

3.  1909: Monarchy (King Rama V); Western colonization period  the first registration law was enacted specified the preparation and maintenance of population registration and creation of birth and death registration.  1917, enforced births and deaths registration throughout the kingdom. Civil Registration System

4.  1936: The democratic revolution  creation of a network of local registry office, acting registrars, laid down clear guidelines for the registration of birth, death, fetal death (for the first time)  1956 Comprehensive civil registration act  increased number of registration offices spreading over the entire country Civil Registration System

5.  1972 Revise civil registration act (Military government)  appointment hierarchy of registration authorities  laid down clear procedures for vital registration  specified types of informants place and time for registration, forms, functions, responsibility of registrars, and other requirement for registration.  1982 the Population Identification Number Project. Start of the computerized population database. Civil Registration System

6. <<BACK MOI Central Data Processing

7.  National Authority: Bureau of Registration Administration Department of Local Administration, Ministry of Interior  Operates and maintains the data base for the entire population of the country, and issues identity cards and household booklets Civil Registration System

8. Citizen Identification Number  Citizen ID issues at the of birth registration  Called 13 Digits number  The number is needed when transact with government and many non government agencies:  getting free healthcare services  enrolling children to free education  asking for bank account.

9. Citizen Identification Card 1969-1986 Typing machine ID card 1987 – 1996 Computer Printout ID card Current Smart card type ID card

10. Vital statistics system  The compilation of vital statistics was initiated in 1920  Vital Statistics Division was established in MOPH in 1942.  1993 Health Information Center, Bureau of the Health Policy and Strategy, the Office of the Permanent secretary of the MOPH.

11. Ministry of Interior Central Registry Ministry of Public Health Compile, code, validate and process statistics Provincial Health offices MOI Local Register Copy Birth/ Death list Aggregated report by Province Hospitals Send copy of death certificates Printed Annual Vital statistics report Copy birth/death list for validation Vital statistics Before 1996

12. Weakness of the systems  Discrepancy of birth/death counts between report from provincial health offices and MOI central registry  Not timely: report lag time 2-3 years  Cannot validate cause of death  Need a lot of data entry personnel to enter data from hospital’s death certificate

13. Streamline vital event data between MOI & MOPH 1996, The Ministry of Public Health has signed an agreement with the Department of Local Administration, Ministry of Interior, regarding utilization of data in the central registration database of the administration, in order to reduce redundancy of birth, death data. The Department of Local Administration, Ministry of Interior, will send the data relevant to death of all the persons who have been registered birth, dead from the central registration database to the Office of Permanent Secretary of the Ministry of Public Health.

14. After 1996 - Present Ministry of Interior Central Registry Ministry of Public Health Provincial Health offices Report statistics back to provinces Hospitals Web entry death certificates (start 2006) Printed/ Web Vital statistics report Electronic files Compile, code, validate and process statistics

15. Health care service administrative data  2001 implemented Universal care program  3 Major health insurance schemes  Civil Servant Medical Benefit Scheme (CSMBS) 5.6 million civil servants and their dependants (9% Pop.)  Social Security Scheme (SSS) 8.8 million private employees (14% Pop.)  Universal Health-care Coverage Scheme (UCS) 45 millions (77 % of Pop)

16. Casemix Information System  Diagnosis Related Groups (DRGs) : acute in-patient financing tool  Insurance schemes reimburse hospitals using DRGs  5 millions in-patients (7 millions admission)/year  Standard data sets for health insurance  Patient demography  Citizen ID  Diagnosis and Procedure (ICD Coded)  Patient discharge status (e.g. recovery, death, transfer etc.)

17. Flow of vital event registration Death inside hospital Death outside hospital Death certificate by doctorDeath notification by village head Death registration at district office or municipality Ministry of Interior ICD-10 coding at MoPH (BPS) 40% 60% Medical death certificate form (In-hospital) with COD Death notification form (Non-hospital) with COD On-line system Electronic file transfer monthly

18. Death counts and Cause of Death (COD)  Death data processed Total death ~400,000 / year Code cause of death with ICD 10 Compile and Analyzed Annual reports in print and web format Provide provinces population, birth, death information every month Decrease ill defined COD (R0-R99) from 45% to 37%

19. Problems of Causes of death data  High % of ill-defined causes of death Non-hospital death (relatives provide general symptoms or senility as the causes of death) In-hospital death (doctors use mode of death instead of the causes)

20. Problems of Causes of death data  Misclassification of causes of death In-hospital death (doctors select and write the wrong COD) Non-hospital death (relatives bias the causes of death to avoid stigma such as HIV)

21. Ill-defined causes of death year 2000 Analyzed from Vital registration databases 2000, MoPH

22. Improving COD statistics  Improving COD data for in-hospital death  Improving COD data for non-hospital death  Validation for COD statistics through Verbal Autopsy

23. Improving in-hospital COD data  Training for medical doctors to define actual COD in medical death certificate Reduce mode of death, un-specified causes, injury code Reduce misclassification, wrong selection  Medical records and coding audit for better quality of diagnosis of diseases and causes of death

24.  Using electronic in-patient records (administrative data – reimbursement data) for defining outside hospital COD  Match death outside hospital with recent hospitalization using citizen identifier number (13 digit number)  Using local health personnel to provide COD (accompanied with VA tool and medical history) Improving non-hospital COD

25.  Verbal autopsy (VA) questionnaire is another tool that can use to improve Cause of Death (COD) information.  Thailand is piloting a project: using a customized VA tool by rural health personal to interview the deceased’s relative before registering to civil registration system  Preliminary results: Ill-defined COD (ICD 10 code R00-R99) decrease from 41%(2007) to 27%(2008) and 25%(2009) Improving non-hospital COD

26. Improve accuracy of Maternal Mortality Ratio (MMR) Calculation  Thailand faces unreliable MMR.  Many MMR reporting figures that are not consistent depend on the sources of data.  MMR calculation

27. MMR from different sources

28. Identify Maternal death who gave live birth from Birth-Death Registration From: Chandoevwit W & et al, Using Multiple Data for Calculating the Maternal Mortality Ratio in Thailand. Thai Development Research Institute Quarterly Review. 2007

29. Identify Maternal death with still birth & neonatal death From death registration & heath service records From: Chandoevwit W & et al,Using Multiple Data for Calculating the Maternal Mortality Ratio in Thailand. Thai Development Research Institute Quarterly Review. 2007