Based on our knowledge of pathophysiology and disease epidemiology, a certain age pattern of deaths due to a cause can be expected. For example, we know that deaths due to cancer generally increase with age. We use this fact to assess the quality of cause of death statistics. If the age pattern of deaths attributed to a cause is found to deviate sharply from the expected age pattern, we suspect the validity of the cause of death statistics. The best way to perceive major deviations in age pattern is to look at graphs indicating the age pattern of deaths attributed to a cause. We plotted such graphs for the top ten causes, using data for five consecutive years (1991 to 1995). Apropos SCD-Rural, these causes included suicide, excessive heat, gastroenteritis, tuberculosis, bronchitis, pneumonia, paralysis, congestive heart disease, heart attack and jaundice. In case of MCCD, these causes included: ischaemic heart disease, tuberculosis, lower respiratory tract infection, low birth weight, cerebrovascular disease, diarrhoeal disease, road accidents, chronic obstructive pulmonary disease, fires and birth asphyxia / birth trauma. Twenty such graphs were plotted (10 for SCD-Rural and 10 for MCCD) where each graph had 10 plots at the rate of two plots (female and male) for each year. The plots were visually examined, for unusual age patterns if any. No instance of unusual age pattern was detected. Assignment of deaths to neoplasm are known to be affected by deficiency in cause of death reporting systems. Hence the age pattern of such deaths as reported by SCD-Rural in 1995 and MCCD in 1995, 1996 (the graphs are not shown here) was examined. It is expected that mortality due to cancers increases as age advances. The plot of data from SCD-Rural 1995 also reflected the expected trend. But the plots of data from MCCD showed a decline in cause specific death rate after 55 years which we inferred was most probably due to the under-diagnosis of cancers at older ages. On the whole, it was found that by and large age-sex pattern of deaths attributed to major causes, by the Indian cause of death reporting systems followed expected patterns. However, the existence of deviations in age pattern for a few causes cannot be ruled out. The overall performance of this aspect of the system is deemed satisfactory.

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We have examined the cause of death reporting system in India, using the nine aforementioned criteria to assess the usability of the cause of death statistics generated thereof . In Table -3.12 we summarize the findings and give our own rating of the contemporary Indian cause of death reporting system. We have followed a three category rating consisting of satisfactory, tolerable and poor. The prime factors affecting usability of the cause of death statistics in India are (a) poor coverage, (b) tendency to assign deaths to residual and "unclassifiable" categories, (c) long delay and irregular publication of statistics, and (d) lack of systematic screening. We present herewith our subjective assessment of factors contributing to various aspects of poor performance, and then discuss possible measures that we think will improve the usability of cause of death statistics in India.

Poor coverage has two aspects, namely (a) a total lack of reporting from certain areas, and (b) under- reporting from other areas. These areas are sample villages in case of SCD-Rural and non-reporting municipalities in case of the MCCD. Total non-compliance is a result of lack of awareness. A visit to a few SCD-Rural training programmes in Andhra Pradesh during the year 1998 revealed that some PHC medical officers were totally unaware of the cause of death reporting system that was supposed to operate in their area. Total apathy reigns supreme at all levels, regardless of whether the areas concerned are urban or rural. Most health care institutions, clinical teams, medical attendants and municipal offices are manifestly guilty of either ignorance or complacency, thus contributing to very poor coverage by cause of death reporting systems. Much of this apathy and managerial inattention could be attributed perhaps to the fact that the data is being analysed at the national level. There is neither any mechanism or any effort to analyse cause of death data at the state level and use the results for state level health policy analysis. Consequently, field agents and medical practitioners neither have any means of direct feedback about the nature of utilisation of data collected by them nor do they perceive any stake in the latter. This contributes to a gradual deterioration in the accuracy of cause of death statistics.

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A review of the state of cause of death reporting systems and revamping of the is needed. It is imperative for each state to build an infrastructure for local analysis of causes of death. Sponsored research to analyse cause of death statistics and the implications for health policy, will, it is hoped, generate the requisite enthusiasm for usable statistics. In addition, state departments of health and municipal administration need to pay some managerial attention and periodically review the performance of cause of death reporting systems. We feel that if the initiative is taken up by the health and municipal administration departments, consecutively for a period of, say, five years, the coverage of the MCCD scheme would improve substantially. It is our conjecture that once coverage is increased substantially to about 80% of estimated deaths, it is likely to sustain itself without the need for much managerial and supervisory resources. A drive is in order, so that there is widespread awareness of the links between filing of individual cause of death reports and the utility of cause of death statistics in planning and policy analysis. The RBD Act provides for a fine of upto Rs. 50 for the absence of, or incorrect of filling of cause of death reports. Our experience in Andhra Pradesh proves that this provision has not been used at all. The fine prescribed by the RBD Act is more of a token amount than a real financial burden on health care providers. We feel that this fact can be suitably exploited to increase awareness among health care providers about filing cause of death report so that the fine is an effective reminder to defaulting health care providers, enabling them to comply with the legal requirement of filing a cause of death report.

The high incidence of unclassifiable deaths can be attributed to report-writing skills. Chiefs of clinical units do not appropriately emphasize the importance of writing up the cause of death report. Short term training programmes that help build cause of death report writing skills are necessary to remedy this lacuna. Non maintenance or poor maintenance of medical records also contribute to inaccurate assignment of cause of death. Faced with a situation of inadequate information from medical records, the physician writing the cause of death report tends to the assign the death to unclassifiable category or to some miscellaneous codes. Hence the RBD Act needs further amendments requiring health care providers to maintain appropriate medical records in order to facilitate accurate classification of cause of death.

Delay in compilation and publication of cause of death statistics can be further reduced by computerising the operations. At present a lot of the tabulation work is done manually. Some amount of computerisation has already been implemented in the office of the RGI, which in turn has also been subcontracting data entry to private computer service providers. Computerisation needs to be enforced at the state level, so that state level statistics can be published locally and utilised to inform state health policies. The tabulation and publication of state level statistics should be decentralised to State Vital Statistics offices. If the operations are computerised at the state and municipal level, this decentralisation can be achieved without any significant addition to current staff. Suffice to say that computerisation of cause of death report filling and collation is essential.

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Valid and reliable statistics on cause of death is an essential input for the 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 the writing and filing 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 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 the utility 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 the 1990s using nine criteria for utility. 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 proportions 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 the 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. We recommend, based on our subjective understanding of the problems, certain measures required to improve the utility of cause of death statistics in India. We propose that a drive be launched by the 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 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 improve coverage substantially. Other measures recommended by us include: (a) training programmes to hone 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, both 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.) making the maintenance of records mandatory in hospitals and health care institutions . We are unable to make any definite recommendations specifically for the rural areas, since system has been revamped recently. We wish to point out that the cause of death columns added to the SRS data collection forms do not provide for recording of symptoms necessary for the systematic screening and coding of cause of death reports. However, it is too early to sit in judgment on the new system. Research is recommended in order to evaluate the performance of the new cause of death reporting system in rural areas.

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