Tuberculosis mortality differentials in Indonesia during 2007-2008: evidence for health policy and monitoring

Implementation research for developing Civil Registration and Vital Statistics (CRVS) Systems: lessons from Indonesia

Civil Registration and Vital Statistics (CRVS) systems are the optimal source for data on births, deaths and causes of death for health policy, programme evaluation and research. In Indonesia, indicators such as life expectancy at birth, childhood and maternal mortality rates and cause-specific death rates need to be routinely monitored for national health policy. However, the CRVS system is not yet producing reliable vital statistics, which creates a challenge for evidence-based health action. In 2019, the Indonesian government released a national strategy for the CRVS system, with targets for improved coverage and data quality by 2024. This article describes findings from a programme of formative and implementation research to guide the application of the national strategy. At first, a detailed CRVS assessment and gap analysis were undertaken using an international framework. The assessment findings were used to develop a revised business process model for reporting deaths and their causes at village, subdistrict and district level. In addition, a field instruction manual was also developed to guide personnel in implementation. Two field sites in Java-Malang District and Kudus Regency were selected for pilot testing the reporting procedures, and relevant site preparation and training were carried out. Data compilations for Malang in 2019 and Kudus in 2020 were analysed to derive mortality indicators. High levels of death reporting completeness (83% to 89%) were reported from both districts, along with plausible cause-specific mortality profiles, although the latter need further validation. The study findings establish the feasibility of implementing revised death reporting procedures at the local level, as well as demonstrate sustainability through institutionalisation and capacity building, and can be used to accelerate further development of the CRVS system in Indonesia.

Building Capacity for Mortality Statistics Programs: Perspectives from the Indonesian Experience

Information on deaths by age, sex, and cause are primary inputs for health policy and epidemiological research. Currently, most developing countries lack efficient death registration systems that generate these data on a routine and timely basis. The global community is promoting initiatives to establish and strengthen national mortality statistics programs across the developing world. Building human, technical, and institutional capacity to operate these programs are essential elements for the program. In Indonesia, the government has established a national Sample Registration System (SRS) covering a population of 9 million and is looking toward further scaling up of operations of the mortality statistics program in conjunction with expansion of the national Civil Registration and Vital Statistics (CRVS) systems. This article reports the theoretical and practical perspectives gained from experiences in developing human capacity in the Indonesian context. These perspectives are described in terms of the institutional, personnel, and functional components of the program for collection, compilation, analysis, and utilisation of mortality and cause of death data. The article also describes the challenges and potential solutions for implementing capacity building activities at national and subnational level. In conclusion, the need for and availability of training resources are discussed, including the potential for involvement of public health academia and international collaborations within a research framework on program management, quality evaluation, and data utilisation. Adequate attention to capacity building is essential to ensure the success and sustainability of national mortality statistics programs.

Elements of a strategic approach for strengthening national mortality statistics programmes

Information on cause-specific mortality from civil registration and vital statistics (CRVS) systems is essential for health policy and epidemiological research. Currently, there are critical gaps in the international availability of timely and reliable mortality data, which limits planned progress towards the UN Sustainable Development Goals. This article describes an evidence-based strategic approach for strengthening mortality data from CRVS systems. National mortality data availability scores from the Global Burden of Disease study were used to group countries into those with adequate, partial or negligible mortality data. These were further categorised by geographical region and population size, which showed that there were shortcomings in availability of mortality data in approximately two-thirds of all countries. Existing frameworks for evaluating design and functional status of mortality components of CRVS systems were reviewed to identify themes and topics for assessment. Detailed national programme assessments can be used to investigate systemic issues that are likely to affect death reporting, cause of death ascertainment and data management. Assessment findings can guide interventions to strengthen system performance. The strategic national approach should be customised according to data availability and population size and supported by human and institutional capacity building. Countries with larger populations should use an incremental sampling approach to strengthen CRVS systems and use interim data for mortality estimation. Periodic data quality evaluation is required to monitor system performance and scale up interventions. A comprehensive implementation and operations research programme should be concurrently launched to evaluate the feasibility, success and sustainability of system strengthening activities.

Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review

Introduction

Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies.

Methods

A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest.

Results

The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time.

Conclusions

The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.

The WHO 2016 verbal autopsy instrument: An international standard suitable for automated analysis by InterVA, InSilicoVA, and Tariff 2.0

BACKGROUND

Verbal autopsy (VA) is a practical method for determining probable causes of death at the population level in places where systems for medical certification of cause of death are weak. VA methods suitable for use in routine settings, such as civil registration and vital statistics (CRVS) systems, have developed rapidly in the last decade. These developments have been part of a growing global momentum to strengthen CRVS systems in low-income countries. With this momentum have come pressure for continued research and development of VA methods and the need for a single standard VA instrument on which multiple automated diagnostic methods can be developed.

METHODS AND FINDINGS

In 2016, partners harmonized a WHO VA standard instrument that fully incorporates the indicators necessary to run currently available automated diagnostic algorithms. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality. This VA instrument offers the opportunity to harmonize the automated diagnostic algorithms in the future.

CONCLUSIONS

Despite all improvements in design and technology, VA is only recommended where medical certification of cause of death is not possible. The method can nevertheless provide sufficient information to guide public health priorities in communities in which physician certification of deaths is largely unavailable. The WHO 2016 VA instrument, together with validated approaches to analyzing VA data, offers countries solutions to improving information about patterns of cause-specific mortality.

Record-linkage comparison of verbal autopsy and routine civil registration death certification in rural north-east South Africa: 2006-09

Background: South African civil registration (CR) provides a key data source for local health decision making, and informs the levels and causes of mortality in data-lacking sub-Saharan African countries. We linked mortality data from CR and the Agincourt Health and Socio-demographic Surveillance System (Agincourt HDSS) to examine the quality of rural CR data.

Methods: Deterministic and probabilistic techniques were used to link death data from 2006 to 2009. Causes of death were aggregated into the WHO Mortality Tabulation List 1 and a locally relevant short list of 15 causes. The matching rate was compared with informant-reported death registration. Using the VA diagnoses as reference, misclassification patterns, sensitivity, positive predictive values and cause-specific mortality fractions (CSMFs) were calculated for the short list.

Results: A matching rate of 61% [95% confidence interval (CI): 59.2 to 62.3] was attained, lower than the informant-reported registration rate of 85% (CI: 83.4 to 85.8). For the 2264 matched cases, cause agreement was 15% (kappa 0.1083, CI: 0.0995 to 0.1171) for the WHO list, and 23% (kappa 0.1631, CI: 0.1511 to 0.1751) for the short list. CSMFs were significantly different for all but four (tuberculosis, cerebrovascular disease, other heart disease, and ill-defined natural) of the 15 causes evaluated.

Conclusion: Despite data limitations, it is feasible to link official CR and HDSS verbal autopsy data. Data linkage proved a promising method to provide empirical evidence about the quality and utility of rural CR mortality data. Agreement of individual causes of death was low but, at the population level, careful interpretation of the CR data can assist health prioritization and planning.

Stroke mortality variations in South-East Asia: empirical evidence from the field

BACKGROUND

Stroke is a leading cause of death in Asia; however, many estimates of stroke mortality are based on epidemiological models rather than empirical data. Since 2005, initiatives have been undertaken in a number of Asian countries to strengthen and analyse vital registration data. This has increased the availability of empirical data on stroke mortality.

AIMS

The aim of this paper is to present estimates of stroke mortality for Indonesia, Myanmar, Viet Nam, Thailand, and Malaysia, which have been derived using these empirical data.

METHODS

Age-specific stroke mortality rates were calculated in each of the five countries, and adjusted for data completeness or misclassification where feasible. All data were age-standardized and the resulting rates were compared with World Health Organization estimates, which are largely based on epidemiological models.

RESULTS

Using empirical data, stroke ranked as the leading cause of death in all countries except Malaysia, where it ranked as the second leading cause. Age-standardized rates for males ranged from 94 per 100,000 in Thailand, to over 300 per 100,000 in Indonesia. In all countries, rates were higher for males than for females, and those compiled from empirical data were generally higher than modelled estimates published by World Health Organization.

CONCLUSIONS

This study highlights the extent of stroke mortality in selected Asian countries, and provides important baseline information to investigate the aetiology of stroke in Asia and design appropriate public health strategies to address the rapidly growing burden from stroke.

Mortality measures from sample-based surveillance: evidence of the epidemiological transition in Viet Nam

OBJECTIVE

To report methods and results from a national sample mortality surveillance programme implemented in Viet Nam in 2009.

METHODS

A national sample of 192 communes located in 16 provinces and covering a population of approximately 2.6 million was selected using multi-stage cluster sampling. Deaths for 2009 were identified from several local data sources. Record reconciliation and capture-recapture methods were used to compile data and assess completeness of the records. Life tables were computed using reported and adjusted age-specific death rates. Each death was followed up by verbal autopsy to ascertain the probable cause(s) of death. Underlying causes were certified and coded according to international guidelines.

FINDINGS

A total of 9921 deaths were identified in the sample population. Completeness of death records was estimated to be 81%. Adjusted life expectancies at birth were 70.4 and 78.7 years for males and females, respectively. Stroke was the leading cause of death in both sexes. Other prominent causes were road traffic accidents, cancers and HIV infection in males, and cardiovascular conditions, pneumonia and diabetes in females.

CONCLUSION

Viet Nam is undergoing the epidemiological transition. Although data are relatively complete, they could be further improved through strengthened local collaboration. Medical certification for deaths in hospitals, and shorter recall periods for verbal autopsy interviews would improve cause of death ascertainment.