Sofoora Kawsar Usman is a 2019 University of Melbourne Data for Health (UoM D4H) CRVS Fellow and the Assistant Director for Health Information and Research with the Maldives Ministry of Health (MoH). Sofoora leads the statistics section of the division, where a key responsibility of her role is the analysis of data collected from health facilities and the dissemination of these data in line with the needs of stakeholders.
As much of Sofoora’s work involves collating and analysing mortality data, Sofoora became interested in undertaking a UoM D4H Fellowship. In 2019, Sofoora spent six weeks in Melbourne with D4H staff, building her skills to conduct mortality data analyses and to identify ways to improve the Maldivian death registration system.
The Maldives consists of twenty administrative atolls, or groups of islands, across which there are 185 inhabited islands. While this creates geographic challenges in the timely dissemination of mortality data, there are also enabling factors: Internet is widely accessible across the country, and deaths must be registered before the deceased can be buried, meaning the death registration system is 100 percent complete. While completing her Fellowship, Sofoora knew that she wanted to leverage these enabling factors to improve the timeliness and quality of the country’s mortality data.
In the Maldives, death notifications are completed via a triplicate copy system. Physical copies of death certificates are distributed to the family of the deceased, the atoll council, and to the Department of National Registration (DNR). Previously, Sofoora’s department would only receive access to these data after DNR completed their data entry processes, which often resulted in delays of more than 18 months. This posed a challenge for MoH, who is responsible for coding mortality data and releasing it to the public in a timely manner. As there are many foreign doctors who do short-term contracts in the Maldives before leaving the country, conducting follow-ups with certifying doctors for clarifications was challenging. During her Fellowship, Sofoora conducted a Business Process Mapping exercise with the support of UoM D4H experts, to identify obstacles to the timely dissemination of data and explore potential solutions. She believes this process was critical to enabling change.
Before I did my Fellowship, I knew there were problems, but I didn’t know how to identify where the problems were lying ... Once we identified what was needed in the system, it took a very short time to develop and implement as a collective effort of all stakeholders.
Sofoora Kawsar Usman, 2019 CRVS Fellow
Following the Business Process Mapping exercise, Sofoora had a much better understanding of the system’s bottlenecks and how they might be alleviated. She developed a series of recommendations, including regular audits of death forms and the implementation of an online vital registration system. With combined efforts from several key agencies involved in the CRVS process including MoH, these recommendations are now being rolled out in the Maldives. Sofoora emphasises the role of Business Process Mapping in the development of solutions. By the end of the year, all twenty atolls and greater Malé will operate using this system, through which MoH has real-time access to death notifications.
In the interim, MoH has also been implementing temporary measures to reduce delays through the use of Excel spreadsheets and scanned copies. “The real-time system is going at a fast pace because we know what has to be done,” says Sofoora. “We already have the infrastructure; we already have trained people. Once we identified what was needed in the system, it took a very short time to develop and implement as a collective effort of all stakeholders.”
As part of her Fellowship, Sofoora was eager to explore ways of improving data quality, with a focus on building capacity for data analysis. Previously, Sofoora and her colleagues sought frequent external advice when conducting annual mortality data analyses. “We weren’t able to conduct data analysis on our own,” she says. “We used to write to the regional World Health Organisation office in Delhi and ask, ‘Are these garbage codes? Should we omit ‘R or ‘Z’ codes? How do we treat them?’ and they would advise. We were not able to do much ourselves because we were not trained.”
Sofoora wrote her Fellowship paper on the use of the ANACONDA (Analysis of National Causes of Deaths for Action) application to evaluate the quality of mortality and cause of death data. She conducted several analyses of Maldivian mortality data, including comparisons with data from the Global Burden of Disease study. It was during this work with ANACONDA that Sofoora discovered a seven-year discrepancy between her results and the official life expectancy data for the Maldives, largely due to differences in the population data used. She used her findings to demonstrate several issues in the data and to query the National Bureau of Statistics (NBS), which resulted in a significant revision of the country’s official data. Sofoora continues to implement her learnings and use ANACONDA for routine data analysis. She believes the evidence it is producing will lead to a significant improvement of the data, and she considers it a success that MoH has now mandated the use of ANACONDA.
“Even if I am no longer in my role in the future, now anybody who is working in the system is required to use ANACONDA for the analysis of deaths.” Sofoora also used her Fellowship to check the quality of 158 Medical Certification of Cause of Death (MCCOD) forms. She found that only two forms were filled out comprehensively, which has an impact on the quality of the resulting data. Sofoora identified the need for more extensive training of doctors in medical certification and the need for a policy in that area. Recognising the high turnover of foreign doctors in the Maldives, she made the recommendation of mandatory online MCCOD training and assessment for all doctors commencing work in the country.
2019 CRVS Fellows. Left to right: Adauto Martins Soares Filho, Suresh Mehata, Tofiq Hassan Shawon, Sofoora Kawsar Usman, May Thu Zaw, Dibakar Sharma
Sofoora speaks highly of the Fellowship and of the support she received from UoM D4H staff. “The whole team has been very supportive,” she says. “Dr Tim Adair was my principal supervisor and I am very comfortable with him. Even now when I’m not very sure about something, I always approach Dr Adair. I cannot stress enough how helpful he and the team have been.” She also emphasises the value of the international networks created by the Fellowship.
“What we are doing during the Fellowship is what we are doing every day at home, so when we return to our countries, it is very valuable to have a network of other professionals for support.” Sofoora is grateful for opportunities that have arisen as a result of the Fellowship, including the opportunity to present at the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) Statistics Week, and to contribute to an associated publication. “Some very good things have happened as a result of the Fellowship,” she says. Dr Adair believes her work and learning have been invaluable.
Sofoora has made the most of opportunities offered through the CRVS Fellowship, which I believe has been very beneficial for the Maldivian CRVS system. She learned some valuable skills with which she identified key issues and made recommendations, several of which are being successfully implemented. Her dedication and skills will undoubtedly result in better evidence on the health of the Maldives population.
Dr Tim Adair, UoM D4H Principal Research Fellow
Dr Adair believes her work and learning have been invaluable.
“Sofoora has made the most of opportunities offered through the CRVS Fellowship, which I believe has been very beneficial for the Maldivian CRVS system,” he says. “She learned some valuable skills with which she identified key issues and made recommendations, several of which are being successfully implemented. Her dedication and skills will undoubtedly result in better evidence on the health of the Maldives population.”
Sofoora plans to continue to work to improve the sustainability of the CRVS system in the Maldives. She hopes to formalise some of the informal processes that occur in order to ensure their longevity.
“Since the Maldives is a very small country, I can call someone in another department or ministry and make a request. We all know each other, and we bump into each other every day. But we need to formalise these activities and ensure that we can continue to build on the work that we have done, regardless of who is working in specific roles.”
Sofoora will continue to conduct internal advocacy to achieve sustainable outcomes. “I see it as my responsibility as a government worker to support our politicians and policy-makers to understand the benefits of these kinds of systems and activities. It may take time, but this buy-in and commitment are essential.”
Eventually, she would like to transition into academia, and she hopes that her MoH colleagues will take full advantage of opportunities provided by UoM D4H. “I might not be working in this capacity here in the future, so I am always encouraging my colleagues to apply for CRVS training opportunities with the University of Melbourne.”
Sofoora would like to thank the Maldives Ministry of Health, the University of Melbourne Data for Health team and the Bloomberg Philanthropies Data for Health Initiative for making her Fellowship possible.
I see it as my responsibility as a government worker to support our politicians and policy-makers to understand the benefits of these kinds of systems and activities. It may take time, but this buy-in and commitment are essential.
Sofoora Kawsar Usman, 2019 CRVS Fellow