Filling gaps in mortality data through a national surveillance system

It was feasible to create a new system to collect data at the community level in Mozambique and aggregate it for use in health planning, according to a journal supplement written and edited by Countdown researchers and published in The American Journal of Tropical Medicine and Health.

This has tremendous implications for sub-Saharan Africa and other settings where civil registration and vital statistics systems are poorly functioning and would take significant investments in time and money to reach adequate coverage. Yet, information on timing and location of births and deaths and causes of death is crucial to inform country monitoring and prioritize action in the context of the Sustainable Development Goals  and other health goals.

“If we are serious about improving the fundamentals of public health, a concerted and sustained effort is needed from global donors, international agencies, and country governments to address the painful gap in information on mortality by cause in high-mortality settings,” Ties Boerma, the guest editor for the supplement and former project director of Countdown to 2030, wrote in the supplement.  “Efforts to improve civil registration and vital statistics in all countries are commendable and necessary but will unlikely solve the mortality statistics gap in the near future. Mortality surveillance systems with verbal autopsy,  combined with population-based surveys and improved medical certification of the cause of death and reporting by health facilities, are a critical intermediate step towards full birth and death (with cause) registration systems and need to be prioritized. The ability to measure excess mortality due to the COVID-19 pandemic on a regular basis is just one example of the immediate value of such systems for public health.”

The supplement titled ” Building a Sample Vital Statistics System: Results From Countrywide Mortality Surveillance for Action (COMSA) in Mozambique” includes six original research articles and two commentaries. The Countrywide Mortality Surveillance for Action (COMSA) Mozambique [COMSA] project began data collection in 2018 and in ongoing. Researchers from the Instituto Nacional de Saude (National Institute of Health) and the Instituto Nacional de Estatistica (National Institute of Statistics) implement the project with technical support from researchers at the Johns Hopkins Bloomberg School of Public Health. Funded by the Bill & Melinda Gates Foundation and other donors, the projects is one of several to implement sample vital registration systems in Africa.

Common Questions about the COMSA project:

How did the project generate mortality data?

The project selected 700 nationally representative geographic clusters with about 740,000 people, then hired community residents to routinely visit homes and collect data on births and deaths. A separate team of data collectors later conducted verbal and social autopsies with families of the deceased to obtain cause of death data.

How much did this system cost?

The annual budget translated to about US $1 million, only slightly more costly than the average annual per capita costs of a national demographic and health survey system with one survey every five years.

Can the system generate reliable statistics?

An assessment concluded that the community data collectors missed about half of the vital events. However it is possible to adjustment for this underreporting can be made by conducting independent parallel data collection on a sub-sample of the surveillance population.

Are the cause of death patterns trustworthy?

To improve the accuracy of verbal autopsy, which is known to be an imperfect tool, data from the Child Health and Mortality  Prevention Surveillance (CHAMPS) project’s minimally invasive tissue sampling was used to improve children’s cause of death ascertainment.

Will the project be sustained?

The funding included  developing a “transition plan” to local institutions, and details are described in the supplement.