This study has highlighted the need for reliable and valid local data for National Burden of Disease Estimates. Using the case of Andhra Pradesh in India, the study examines available sources of data and describes their usability. Deficiency in availability of local data is highlighted to draw attention to the need for improving vital statistics, cause of death and epidemiological surveillance systems. The Global Burden of Disease Estimation projects has encouraged internal consistency checks, indirect estimations, synthesis of epidemiological and demographic information, sheer perseverance to tap a wide array of data sources and estimation of missing data points by triangulation. These efforts have made it feasible to generate some estimate of Global and National Burden of Disease. While this is a major achievement, there is a limit upto which plausibility checks and indirect estimates can yield the required information for the increasingly complex policy choices in the health sector.

Valid and reliable statistics on cause of death is an essential input for setting of priorities in the health sector. Major initiatives to systematically identify health sector priorities have used cause of death information. An ideal cause of death reporting system consists of: (a) a fully developed vital registration system with, (b) cent percent medical attendance at the time of death, and (c) full compliance by the health care providers in writing up and transmission of cause of death reports. Developing countries like India are making efforts to operate cause of death reporting systems that are feasible within the given constraints of partially developed registration of vital events, and poor availability of medical facilities. We examine the cause of death reporting systems in India and usability of the statistics. For rural areas, cause of death statistics used to be collected through the SCD-Rural scheme which operated till December 1998. There after, rural cause of death statistics is sought be generated by adding a few columns to capture of cause of death information for deaths reported under the SRS-COD component. For urban areas, there is the medical certification of cause of death (MCCD) scheme extended by state governments, mostly, to municipalities and urban areas. To assess usability of cause of death statistics we examine the SCD-Rural and MCCD data for a period of about five years in the first half of 1990s using nine usability criteria.

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These usability criteria are: (a) content validity of lay reporting systems, (b) adequate coverage and compliance, (c) validity of statistics at sub-national levels of disaggregation, (d) minimal usage of residual categories, such as unclassifiable, or ill-defined conditions, (e) consistency of cause-specific mortality proportion with general mortality level, (f) absence of incorrect assignment of causes with clear age-sex dependency, (g) no case of improbable age-sex distribution by cause, (h) consistency of cause- specific mortality proportion over time, and (i) timely compilation and publication of the statistics.

We find that major factors affecting usability of the cause of death statistics in India are (a) poor coverage, (b) high incidence of unclassifiable deaths, (c) long delay and irregular publication of statistics, and (d) lack of systematic screening. Its unfortunate that enough attention was not paid to cause of death statistics, even in the era of conventional aids to priority setting using mortality based data. We recommend, based on our subjective understanding of the problems, certain steps required to improve usability of cause of death statistics in India. We propose that a drive be launched by the Registrar General and Ministry of Health, Government of India, and all State Governments through the Ministries of Health and Municipal Administration, to improve coverage by cause of death reporting systems. Based on our experience in Andhra Pradesh, we conjecture that simply introducing periodical reviews jointly by the Departments of Health and Municipal Administration, identification of non-reporting municipalities and sample units, and further identification of non-reporting health care institutions sustained over a period of, say, five years will raise coverage substantially.

Other measures recommended by us include: (a) training programs to build up cause of death report writing skills among physicians, (b) compilation and publication of cause of death statistics at the state level, (c) sponsored research on cause of death structure and their policy implications, (d) computerisation of filing, tabulation and flow of cause of death statistics, at the municipality and state level. To reduce the unusually high level of unclassifiable deaths, we recommend that an amendment be brought in the Registration of Births and Deaths Act (RBD Act.) requiring hospitals and health care institutions to maintain medical records. We are unable to make any definite recommendations specifically for the rural areas, since a change in the system has taken place recently. We have some apprehensions about the design of the new system. We point out that the cause of death columns added to the SRS data collection forms do not provide for recording of symptoms. This later information is required for systematic screening and coding of cause of death reports. However, it is too early to make a judgement on the new system. We recommend that research be taken up to evaluate the performance of the new cause of death reporting system in rural areas.

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An important contribution of this study is the advancement of methodological aspects of health state valuation in developing country communities. A health state description system incorporating a graphic description component was developed to facilitate communication in partially literate communities. Some deliberative tools for conduct of health state valuation workshops for educated persons were developed. The experience gained for valuation of health states in developing country settings, we hope, will help in future research.

On the substantive aspect of the subject, this study has shed some light and raised many questions about the nature of the health state valuation process in our minds. Analysis of test retest data on ordinal ranking of health states, valuation of own health state and differences in distribution of valuations at the community level, all lead us to hypothesize that the true health state valuation in our minds is a multi- valued fuzzy set with different degrees of clarification. Conventional theory that the true valuation is a single valued function, is not consistent with our observations, and appears intuitively less appealing.

The incidence of measurement error and the our present understanding about the nature of valuation process, would suggest that community level valuation of health states require large sample size and also repeated measurements. Large sample sizes would help minimise the measurement error for mean values estimated form community surveys. Repeated measures, it is anticipated, will occasion repeated deliberation by the valuers and thereby help clarification of their value sets. The tradeoffs between sample size and repeated measurements will have to be studied. So far, researchers have focused on the mean valuations. This study has demonstrated that community valuation of all health states do not follow the same distribution. Differences in distribution of valuations by the community for different health states has policy implications, and hence, should be the subject of further research.

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The study provided an opportunity for a comprehensive estimation of disease burden in AP during the 1990s. Clearly (a) lower respiratory tract infections (LRI), (b) diarrhoeal diseases, (c) low birth weight (LBW), (d) tuberculosis and (e) falls were the top causes of disease burden in AP, during the 1990s. These five conditions showed up in the ten leading causes of burden list from estimates using expert rated disability weights as well as community rated disability weights. Three out of these five, namely: LRI, diarrhoea, and LBW, are public health problems for infants and children. They should serve as stark reminders to the persisting problems of poor nutrition, water supply and sanitation. Tuberculosis, another infectious disease, continues to be a major problem. Currently there are programmes seeking prevention and treatment of these problems. For example: the reproductive and child health programmes, programme to build awareness about usefulness of oral rehydration therapy, tuberculosis control programmes. Obviously, the agenda to control diseases due to infection - malnutrition - poor hygiene complex remains unfinished.

Falls as a major cause of burden strikes one as a little bit of surprise. There is hardly any discussion about falls as a public health problem. Lack of attention on falls as a major cause of disease burden, is largely due to ignorance about the size of problem attributable to falls. These estimates should serve to focus attention to this problem. It is difficult to pinpoint a single cause leading to falls. A variety of causes including (a) design factors and (b) poor compliance to safety norms may be responsible. The first task is to investigate and study a fairly large sample of cases involving falls and identify the causes responsible for it. Only then we will understand, how to go about the business of prevention. Considering that a large part of the burden due to falls is among older children and young adults, investments on study of causes of falls and measures to prevent its occurrence will help alleviate a lot of emotional burden suffered by families, in addition to the personal disease burden factored into the current estimates.

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Self-inflicted injury and fire accidents emerged as major causes of disease burden in the state. These two causes of disease burden clearly reflect larger social, cultural problems and points to the need for urgent social cultural reform. Suicides, mostly among adolescents and young adults is largely due to problems of adjustment due to many factors during the transition phase of a person's life. The high burden on account of fire accidents, particularly among women, is consistent with widespread social ill of bridal harassment, dowry etc. A large proportion of suicides among young women is probably due to the same factors. In addition, the educational systems inability to impart useful economic skills is probably another factor leading to a lot of frustration and suicide among young boys and girls.

The high level of disease burden due to road accidents is a cause for concern. This burden is going to increase, unless appropriate preventive steps are taken urgently. The automobile population is continuing to increase at a very rapid rate and road and traffic signalling infrastructure do not appear to be keeping pace with the same. In addition, we have the problem of poor driving skills. The granting of driving licences in most states is more bureaucratic, rather than functional. There is no system of written examination about knowledge of traffic rules prior to the grant of a driving licence. The driving tests required by law before issue of driving license does not appear to be taken seriously.