Towards improved Civil Registration and Vital Statistics systems during public health emergencies: Reflections from Africa CRVS week

Originally posted on 31 August on BMJ Global Health Blogs

The COVID-19 pandemic has exposed vulnerabilities in the health systems of the Africa Region, including in the civil registration and vital statistics (CRVS) systems. This year’s Africa Civil Registration and Vital Statistics Week explored these with a series of webinars on the theme, Civil Registration and Vital Statistics as an Essential Service for Monitoring and Mitigating the Impact of Emergencies.

During health emergencies, resilient health systems are required for accurate and timely documentation and reporting of death and cause of death, to reveal the true toll of the pandemic on a given population. The emphasis of this topical issue among the region’s CRVS development community and governing bodies, could not have been more timely.

Countries in the African Region continue to struggle with some of the most basic functions of CRVS systems such as counting and reporting of deaths, causes of death and births. According to a survey carried out by the United Nations Economic Commission for Africa, only 18 of 54 countries record and report annual deaths, and four African countries have a level of death registration coverage and cause of death information that meets international standards. WHO also reports that up to 30 of the 47 Member States (64%) had almost no capacity (nascent capacity) at all for CRVS, and 13 (28%) had limited capacity. Only 4 of the 47 Member States could be described as having developed capacity and of these, CRVS capacity in only one country could be described as sustainable; capacity in the remaining three was developed but not sustainable. These statistics are especially worrying during this global pandemic as it means countries’ abilities to assess the true toll of COVID-19 on their populations, including timely measurement of excess mortality, remain severely limited.

Furthermore, these statistics provide an early marker of the likelihood of underreporting of COVID-19 deaths among countries in the region. We expect underreporting to be driven by the fact that in the African Region, many deaths occur outside of the health facility setting, with only one in three deaths captured by official registration systems. There also remain challenges of limited COVID-19 testing, which means that certain COVID-19 deaths may go by uncounted or uncertified as a result of the low capacity for attributing cause of death in many of the countries of the region.

As countries seek to ‘build back better’, and strengthen the resilience of their health systems, a focus on improved national capacities for generation of mortality statistics cannot be over-emphasized. We offer potential solutions for strengthening CRVS across countries of the WHO Africa Region.

First, improved community engagement and participation in the process of reporting and registration of deaths and cause of death could significantly improve the quality of vital statistics available across countries. Advocacy and sensitization among religious institutions, faith-based organizations, local government and chieftaincy systems could be potentially transformative for the improvement of mortality statistics at the community level. Second, the establishment of rapid mortality surveillance systems to bolster capacity for monitoring excess mortality, disaggregated by key equity stratifiers such as sex, age, geographical zones and subnational administrative units, provides an opportunity to improve capacity for real-time counting of deaths, which could be used to inform targeted policy actions concurrently. Third, CRVS systems should be considered as essential services, with uninterrupted functioning, during times like these. Preliminary data reported by African countries to the United Nations Legal Identity Task Force, show that in some countries, CRVS services were suspended and the impact of the lockdown measures taken by governments influenced the utilization and demand of CRVS services. In these countries where CRVS service utilization dropped, there are numerous consequences, including potential deprivation of access to critical social services such as healthcare, education, and humanitarian assistance among certain key populations, as well as potential negative impacts on country health outcomes.

The world has suffered innumerable losses and setbacks from the COVID-19 pandemic. Stagnation on the region’s progress and commitment in improving the availability of vital statistics remains a threat, but it is important that countries continue to prioritize the strengthening and scale up of the CRVS systems to ensure that progress made over the years, is not permanently lost.

WHO AFRO remains committed to supporting Member States in the adoption and implementation of tools and approaches for reporting of deaths and causes of death, including for improved Medical Certification of Cause of death in health facilities; Verbal Autopsy for deaths that occur in communities; and the International Classification of Diseases (ICD-11) for standardized reporting of causes of death. WHO and its partners are also committed to supporting countries in the implementation of rapid mortality surveillance systems, including the establishment representative sentinel mortality surveillance systems, to avail real time information for assessing the impact of the pandemic and measuring excess mortality.

Finally, cross-country lessons sharing on practices for quality and capacity improvement of CRVS systems provide a key platform to pick up innovations from other settings, for replication and sustainable scale-up. Mauritius provides a clear example of where lessons can be learnt on resilient systems for death registration during health emergencies such as the COIVD-19 pandemic.

The commemoration of Africa CRVS week has refuelled the discussion on the importance of CRVS systems, especially during health emergencies and provided impetus for countries in the African Region, to move towards generating and reporting high quality statistics on death and cause of death.  Now is the time!

All authors work at the WHO Regional Office for Africa

Regina Titi-Ofei¹, Hillary Kipruto², Aminata Binetou-Wahebine Seydi³, Benson Droti⁴, Humphrey Karamagi⁵, Prosper Tumusiime⁶

1 Data, Analytics and Knowledge Management Unit

2 Health Information Systems Unit

3 Data, Analytics and Knowledge Management Unit

4 Health Information Systems Unit

5 Data, Analytics and Knowledge Management Unit

6 Universal Health Coverage, Life Course Cluster

Competing Interests: Authors declare no competing interests.

Photo: © WHO / Hery Razafindralambo