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Frequently Asked Questions

Advocacy and legal review
How can my country advocate for improved civil registration?
This paper outlines a six-step approach to building the business case and comprises:
 
  • assessing the current system
  • conducting research and formulating the arguments 
  • identifying, analysing and engaging with stakeholders 
  • presenting the case to the relevant decision-makers.
How can my country advocate for improve vital statistics?
This page outlines activities that demonstrate the value of vital statistics for policy, planning, monitoring and evaluation
Is there a best-practice way to review my country’s laws around civil registration and vital statistics?
The five recommendations to review your country’s CRVS legal and regulatory frameworks are:
  1. Establish an advisory group or legal review committee 
  2. Review key documents and concepts 
  3. Collate and review all existing relevant laws and policies 
  4. Complete the matrix of best practices 
  5. Draft and revise a final report
 
General
What are the links between CRVS and the Sustainable Development Goals?
Strengthened CRVS systems will significantly contribute to achievement of the Sustainable Development Goals (SDGs). In fact, CRVS systems strengthening is a goal in and of itself in the 2030 Agenda.
 
In the SDG framework, CRVS systems are seen from three perspectives: 
 
  • CRVS systems – notably for birth and death registration – are defined as SDG goals in and of themselves, given their contributions to reliable administrative and statistical systems and to the realisation of human rights and sustainable development. 
  • The legal documentation of identity, civil status and family relationships through CRVS will facilitate access to services, rights and entitlements, and thereby the achievement of numerous goals, such as SDG 3 (Good Health and Well-Being), SDG 4 (Quality Education), and SDG 5 (Gender Equality). 
  • The robust population data that CRVS systems generate are essential for monitoring progress towards SDG metrics (that is, the goals, targets and indicators).
 
For more information, read this resource on how CRVS systems matter for SDG development or this summary.
What interventions does Data for Health use to improve cause of death data?
The Data for Health Initiative is improving cause of death information in countries by applying the following interventions:
 
Research helps countries confidently and transparently determine what CRVS interventions work in which kinds of settings. Read more on research priorities for country CRVS strengthening.
 
Read in-depth stories on targeted interventions in Bangladesh, Papua New Guinea and Peru
 
Read country overviews on each Data for Health country
The agencies involved in CRVS in my country are siloed, how can we work together better?

The ‘Ten CRVS Milestones’ framework, used as part of the CRVS assessment and during the design and integration of new interventions, encourages CRVS stakeholders to have a systemic approach to all the essential steps needed for the system to be fully operational.

The ‘Ten CRVS Milestones’ framework is designed to help CRVS stakeholders—policy-makers, managers and development partners—better understand how CRVS systems function as a whole, from end-to-end, by describing the key processes that must be accomplished in any CRVS system.
 

Read more about Ten CRVS Milestones.

How can my country rapidly improve our CRVS system?
Read more about the sequencing actions to strengthen civil registration and vital statistics,
which include: 
  • ensuring high-level political commitment and coordination
  • addressing legal, institutional and operational issues, use IT innovations
  • and increasing awareness and demand, providing incentives.
 
Read how some countries in Asia and the Pacific improved their CRVS systems
Do centralised or decentralised CRVS systems work best?

The CRVS structure used in a given country will depend on local contexts, such as government structure, geographical features, administrative mechanisms and history. 

The challenge facing countries is not necessarily to modify the existing architecture, which may be disruptive and time-consuming, but to find ways of improving performance within its current framework.

Read more about CRVS structures

How do I know if my data are correct, or reliable?
Perform a data quality assessment using the software tool, ANACONDA
Read more about reliable data generated from CRVS systems 
Read more on monitoring CRVS data quality and progress
Read more on redefining unusable, or ‘garbage codes’ that are not helpful for health policy.
What do other countries do?
It can be useful to understand what interventions other similar countries are applying. 
 
On this page, you can find flyers on what interventions are being applied in Data for Health countries and videos where stakeholders describe their country’s experiences in improving their CRVS system and data. 

Coming soon: ‘Stories of change’ will be published on each Data for Health country
Mortality certification and coding
How can we ensure that physician-certified deaths are accurate and recorded in accordance with the international standard and why is that important?

Ideally, death certification should be routinely conducted by trained physicians, supported by national policy and legal frameworks.

Medical certification of cause of death training must be offered at key learning points in a physician’s career. 

Improvements in death certification will be underpinned by the medical community’s understanding of the importance of this task and the obligation physicians have towards their patients for recording their deaths correctly.

Read more about the best-practice approach to provide physicians with ongoing education and training in death certification.

What are mortality decision tables and how they are useful in mortality coding?

Coders in many countries are not medically trained. In mortality coding, understanding causal relationships between the conditions reported in death certificates is very important for the correct application of coding rules. 

To help coders understand causal relationships, we use mortality decision tables contained in the US National Centre for Health Statistics (NCHS) Medical Mortality Data System (MMDS). Decision tables not only help coders understand causal relationships but also ensure the consistent application of complex mortality coding rules by the coders. They are used in both manual and automated mortality coding. 

Read more on mortality coding tools

I’ve heard that some D4H countries use Iris for automated mortality coding – what is it and when should it be used?

Mortality coding can be a complex, time-consuming, and costly process. To address this, many countries are using automated software to generate more reliable and timely cause of death data. One such software is Iris, which allows users to either enter ICD-10 codes, or to enter the causes in free text to then be assigned codes and an underlying cause of death. 

However, there are a number of steps countries should take before implementing Iris. This action guide on implementing Iris describes the five key steps countries should follow when implementing automated mortality coding.

Learn more about from cause of death certification to statistical coding

The ICD-11 has just been released, should we start using that now? Will our coders require re-training?

It’s advised that countries involved in the Bloomberg Philanthropies Data for Health Initiative who are currently using ICD-10 continue using the tool for the remainder of the initiative.

Coders will need to undergo training in the new version of ICD, as the classification is very different to ICD-10.

Read more about the World Health Organization ICD online training tool.

Notification and registration
Are registration and notification the same thing?

No, but they are often confused.

Registration is the act of formally registering an event at a civil registration office. At this point, details of the event are entered into the official civil register by the Registrar.

Notification is the capture and onward transmission of minimum essential information on the fact of birth or death by a designated agent or official of the CRVS or other government (eg health department) system using a CRVS authorised notification form (paper or electronic) with that transmission of information being sufficient to support immediate policy action to prevent premature deaths and the eventual registration and certification of the vital event.

The 10 CRVS milestones framework is a useful diagram to understand the CRVS system as a whole.


 

What are the strategies I can use to improve notification of deaths?
The health sector is an increasingly active player in CRVS through its role in the notification of births and deaths, events that increasingly occur within health institutions or under the care of health personnel.
 
More information:
How can civil registration improve national identity systems?

Civil registration should be the basis of any national identification system and must be strengthened before identification systems are put in place. Read more in our flyer. 

How do I improve registration in my country?
There are some best practice guidelines to improving registration in your country:
  • This flyer is a good overview
  • This list identifies ways to overcome demand-side barriers to reporting and registering births and deaths 
  • On a community level, this page identifies activities that your country can utilize to increase awareness, engagement and participation in birth and death registration. 
What is registration completeness?

The completeness of registration is defined as the percentage of actual births or deaths in a population that are registered. Put another way, it is the number of registered births or deaths divided by the actual number of births or deaths in a population.

 

Completeness of birth registration:

Completeness of death registration:

Read more on completeness of registration 

Read more on methods to assess completeness of birth registration

How do I measure the completeness of death registration for national and subnational populations?

Completeness of death registration can be measured at the national and subnational level using a new empirical method that utilises data that are commonly available at the national and subnational level. Read more.

Read more on why routinely measuring birth and death registration is important

 

Verbal autopsy
How accurate are verbal autopsies?
The accuracy of various diagnostic methods for verbal autopsy, when the data are to be used to inform policy, should be judged by how reliably the method(s) predict the true cause of death pattern in the population. 
 
  • This page describes the outputs of verbal autopsy interventions
  • This page describes the two verbal autopsy questionnaires that are currently in widespread use
  • This page describes the three automated diagnostic methods that are currently widely available (see the ‘Read more’ portion of this page for links to research papers)
What are the challenges associated with automated verbal autopsy?
Read about some of the challenges associated with automated VA training and rollout
How can I send the outputs from automated VA to an existing database platform such as DHIS2 so the results can be readily analysed?
The introduction of routine verbal autopsy into CRVS systems has created a need for automated processing of verbal autopsy (VA) data into health system databases. Verbal autopsy data analysed using InterVA and InSilicoVA can be integrated into DHIS2 using the OpenVA pipeline, while SmartVA can be integrated into DHIS2 using smartva-dhis2. Both integration platforms are currently configured for DHIS2 but use an intermediate storage database that can be configured for other destination database platforms. 

Alternatively, desktop software for the VA algorithms are available for manual use.

 Read more about the OpenVA Pipeline or smartva-dhis2.
 
How does automated verbal autopsy work?

Read about some of the challenges associated with automated VA training and rollout

Why not use verbal autopsies on all deaths?

Verbal autopsy is not a substitute for medically certified cause of death. In general, it is intended for use where there is no physician, and for generating population-level data on proportions and rates of cause-specific mortality. It can also be used to support cause of death diagnosis in cases where there is little clinical information on the deceased such as dead on arrival 'DOA' cases, or community deaths where the certifying physician is unfamiliar with the deceased.

Completing the medical death certificate can be challenging in some cases, especially when death has occurred outside the health facility and where the certifying physician has no access to medical records or diagnostic tests to inform the completion of the certificate. 

In some countries, physicians use automated VA (SmartVA Auto Analyze) to provide additional information so that a death certificate can be issued. This helps avoid instances where the physician refuses to certify the death because of lack of information or writes ‘ill-defined’ or ‘unknown’ as the COD. These deaths can constitute a significant proportion of all deaths in some countries. 

Instituting a system for routinely applying VA methods can yield valuable diagnostic information for health policies. Automated VA techniques can be used by health personnel to interview relatives of the decedent to elicit the main symptoms experienced before death, and then apply a diagnostic tool to identify the probable COD. 

While VA generates cause of death data that are generally less detailed and less reliable at the individual level than those derived using medical certification of cause of death, it can be a cost-effective means of providing useful information about the cause composition of mortality at a population level that can be used to inform health policy.

How can verbal autopsy be integrated into my country’s CRVS system?

The introduction and integration of verbal autopsies into CRVS systems is arguably the most complex and difficult challenge that countries face in trying to improve data for policy. 

Sustainable integration of VA into CRVS systems is more than just a technical challenge. When introducing VA into settings that have limited resources, various system integration issues will need to be carefully addressed during the planning, piloting and implementation stages of VA integration.

Read more in our short guide or read our detailed technical outcome series on CRVS and VA integration

How are deaths in the community integrated to produce vital statistics reports?

We know that relying on hospital-based cause of death data does not paint a full picture of a country’s disease burden, as many deaths in low-and-middle-income countries occur outside of hospital settings. 

When community deaths are captured using verbal autopsy (VA), it is critical to consider the importance of drawing them from a nationally representative sample. This will provide the most accurate representation to allow VA data to be meaningfully integrated into the CRVS system. Countries may wish to use civil registration administrative units to identify the sample, to facilitate data administration. 

Measures should be put into place at various stages of the collection and production cycle of vital statistics. At the first stage where a death notification is generated and a VA is administered, data quality checks should focus on accuracy and completeness of the individual record. As the data become aggregated and move down the line to the agency responsible for reporting vital statistics, the data quality focus will be on accuracy, consistency and plausibility of the data. 

This resource on integrating verbal autopsies into CRVS systems might be a useful read for you and your team.

The verbal autopsy costing and budgeting tool guidance document and tool assists countries with scale up and rollout planning for the application of VA as a function of a national CRVS system.

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