Session 2: Different Perspectives of CRVS -- CRVS and Health

Professor Dr Abul Kalam AzadAdditional Director General & Director, Management Information System

Directorate General of Health Services, MOHFW, Bangladesh

Chair and distinguished participants,

I am sure that all of you understand importance of CRVS System very well.

I shall tell you from personal experience -- why CRVS System matters for health.

Then I shall tell you -- why health matters for CRVS.

However, I mean a CRVS System -- that is electronically maintained.

Let me tell first -- how CRVS can benefit health

Here I shall make 6 points from experience:

1. Communicable Disease Surveillance -- why we will collect same demographic data every time?

2. Routine immunization -- poor estimation of number of children causes wastage of resource or poor protection of children.

3. Two MMR Surveys in Bangladesh -- we missed UN-MDG5 Award.

4. Want to know MDG 4 & 5 status real time.

5. Routine facility MCH data 2011 -- what is happening in the community?

6. Causes of death data -- we do not know for what causes most people are dying.

To resolve problem -- MOHFW started population EHR program in its own way -- to create statistical evidence.

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CRVS systematic assessment -- new lessons

Recently we understood very hard facts from systematic CRVS assessment.

Thanks to the UN ESCAP and WHO-SEARO for assistance.

We observed -- fragmented efforts -- inefficient -- unproductive -- non-standard system -- wastage of resource.

The gaps:

1. The births & death registration project -- only interested to register and issue birth and death certificates;

2. The Election Commission -- interested only about voters;

3. The NSO -- collects 10 CRVS data elements -- but only in sentinel sites -- and cause of death data not according to ICD-10;

4. The MOHFW -- started EHR project -- but not for issuing legal birth or death registration certificate;

5. None of the system is designed in standard way -- and is not inter-operable.

Now let me tell you -- why without health -- effective CRVS may not be possible -- this observation came from our CRVS assessment

1. The birth & death registration project -- will wait say 100 years after registering birth for the death to occur -- not interested to know cause of death;

2. The election commission will only search a voter every 4 or 5 years to update voter list;

3. The NSO does not have enough staff for universal civil registration -- the NSO is non-professional to determine cause of death;

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4. Only MOHFW has responsibility and universal contact with citizens through life course -- in fact -- it does require more CRVS data than others -- it does collect also more CRVS data than other.

New strategy from lessons of CRVS Assessment

1. We agreed to establish a common -- full coverage -- standard -- interoperable -- and -- sharable CRVS system -- together by all stakeholders - public, private and DPs.

We have a good start -- The COIA intervention

Conclusion

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IEDCR experience of Communicable Disease Surveillance

Year 2004 -- I took the responsibility of Director of IEDCR.

We were confronted with risk of rapid global spread of emerging and re-emerging communicable diseases -- like SARS, Bird flu, Nipah virus infection, etc.

My institute was under pressure to build a functional and responsive surveillance system to help forecasting, rapidly investigating and intervening sudden outbreak of any communicable disease.

You can imagine, in a country of 150 million population, mostly rural with not so advanced society, this was really a difficult task.

When surveillance means -- collecting data on respondents at intervals, the most obvious question came.

Why should we write the name, age and sex of the respondents, every time?

These are static data. As alternate, we can make a citizens’ registry with unique ID, name, date of birth and sex information, etc.

An electronically maintained CRVS System can help avoid this repetitive task, and save valuable staff time for other priority and productive work.

Wastage of resource in child immunization

The second problem our ministry of health usually faces.

Bangladesh is a successful country in universal routine child immunization.

However, in no year, we can accurately estimate how many doses of vaccines we would need.

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Because we exactly do not know how many children population we may have in any -- Because we don’t have mechanism to know population denominator other than census year.

In non-census years, we estimate target population size by adjusting year-wise population growth rate by adjusting with census year’s population -- and in doing so, we use same population growth rate for all regions of the country.

It means, either we over-estimate or underestimate children’s number.

And so we buy vaccine doses either in excess or less than needed.

Excess means we waste money -- Less means, we keep some children unprotected.

A good CRVS System could help better manage the situation.

MMR Survey -- Bangladesh missed UN-MDG5 Award

The immediately past two maternal mortality surveys of Bangladesh were done in 2001 and 2010 respectively with a 10 years’ interval in between.

In 2001, the MMR was 320 per 100,000 live births.

Even immediately before release of 2010 survey report there was a widespread assumption that the current figure should be above 290 per 100,000 live births -- because we had no idea that our maternal health interventions were working.

Surprisingly enough, the 2010 survey showed it to be 194 per 100,000 live births.

Just prior to release of the 2010 report, Bangladesh received MDG 4 award from the UN; but missed the MDG 5 award, which was given to Nepal.

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But, after release of our 2010 MMR report, we understood that our maternal health situation was much better than in Nepal.

We missed the MDG 5 award because we did not have an effective CRVS System.

Bangladesh wants to MDG 4 & 5 status real time

Bangladesh seriously wants to achieve MDGs 4 & 5.

The country also believes that it would be possible.

But, we want to know on real time -- how the interventions are working.

An electronic CRVS System integrated with HIS is the best answer.

And experts have identified that 42 MDG indicators out of 60 can be derived from CRVS data.

Routine facility data on child deliveries & IMCI

In 2011, my department collected routine data on about 0.6 million institutional deliveries.

But, we do not know from these data how many deliveries were taken place in the whole country that year -- or what was the institutional or home delivery rates or national skilled birth attendance rate.

Similarly, in 2011, we collected routine data on 25 million U5 children treated for IMCI diseases in health facilities.

But, these huge data could not tell us was the prevalence of those diseases among U5 children.

We do not know for what causes most people die

Recently, we started collecting causes of death data as well as morbidity data from health facilities according to ICD-10.

But, more than 90% of deaths in Bangladesh occurs homes.

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Unless unnatural, these deaths do not require any medical certification or need for finding cause of death for burial or for any other purpose.

If we don’t know why most people die, or what are most common disease burdens -- then how can we plan for preventing unwanted or premature deaths -- or making hospitals -- or creating human resource?

MOHFW’s population EHRs to create statistical evidence

MOHFW wanted to have a better solution to all these problems.

So, the ministry started making a population health registry.

The work began in 2009 and we collected data on 120 million citizens out of 150 million.

The data are now being fed into electronic database to develop into EHRs and to be accessible across the country through electronic devices like computers, laptops, tablets in health facilities and community health workers.

The preparation for this gigantic vision is also moving satisfactorily.

The whole idea is to have reliable and representative statistics available real time to generate evidence and make plans and decisions based on actual situation and thereby also minimize need of costly and time consuming common population surveys.

CRVS systematic assessment -- new lessons

Recently we understood very hard facts.

Thanks to the UN ESCAP and WHO-SEARO that these two organizations assisted us in conducting rapid and the comprehensive systematic assessment of our CRVS System.

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These assessments provided us clear lessons that no silo effort by any individual stakeholder ministry or agency will, in itself, be complete and fulfilling.

We have explored -- how injudiciously, scarce resources are about to be inefficiently used.

We identified number of gaps:

6. The MOLGRDC has a National Birth & Death Registration Project supported by UNICEF, which registers only live births -- no still births -- and deaths without causes of death; the project has been designed only to issue legal birth and death registration certificate -- and not for generate statistical evidence;

7. The National Election Commission, registers only citizens eligible for voting, i.e., citizens 18 years and above;

8. The National Statistics Office collects data on 10 variables of CRVS, viz., birth, death, cause of death not according to ICD-10, marriage, divorce, immigration, emigration, etc.; but only from 1,000 primary sampling sentinel sites -- unable to represent country; and

9. The MOHFW is interested for preparing electronic health record -- not for other issues like issuing legal birth or death registration certificate.

The CRVS assessment identified that none of the system, either individually or collectively is designed in proper way.

All the systems have been designed as stand-alone without intention to mutually benefit each other.

And will not serve whole range of purpose of CRVS system.

Many pertinent observations from CRVS assessment

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5. The birth & death registration project is interested to know about a citizen only after birth and then may be after 100 year when the person will die; and is not interested to know with what causes the person has died;

6. The election commission is interested to know about a citizen only during election -- to know whether or not s/he is eligible for voting or if registered, whether or not surviving during the next election;

7. The national statistics office has no ability to fulfill universal coverage of civil registration -- does not record death according to ICD -- and also have no authority to issue legal birth or death registration certificate;

8. The MOHFW, does not have mandate for issuing legal birth and death certificate;

But, due to having wider health service network and opportunity to access citizens throughout the life cycle; and

Due to relevance of all data parameters of CRVS System with health for understanding an individual’s or overall community or national health status;

The MOHFW in its own right deserve engagement in the national CRVS System as a core stakeholder -- but not excluding others.

Consensus for building national CRVS System as common sharable resource

Bangladesh has great learning from the assessment of CRVS System

From this lesson, we built the consensus that all the stakeholders in Bangladesh will work together for an integrated, shared, standard and inter-operable electronic system.

A good start -- COIA intervention

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We have started an intervention for COIA Country Framework to institutionalize a community based Monitor-Review-Act cycle for improving maternal and child health situation in each small community of the country.

Conclusion

I believe that these example will help us how to build an effective CRVS System and as a result will produce more health for money.

Thank you.

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