The Global Summit on CRVS

Civil Registration System,Sample Registration System

&Annual Health Survey :

Issues and Policy Uses

DR. R. C. SETHIFORMER ADDITIONAL REGISTRAR GENERAL, INDIA

Office of the Registrar General, India18-19th April 2013

OVERVIEWCivil Registration System- Status, Challenges

and Initiatives

Sample Registration System, 2011- Key Results

Annual Health Survey, 2009-2011- Highlights of the baseline survey

Civil Registration System• Comprehensive and complete CRS has multi-faceted

implications on socio-economic development of a country.

• A complete & up to date CRS can provide:

Reliable Statistics on fertility & mortality at all level of aggregations

Almost on a real time basis which is not possible from any sample survey.

Key for evidence based planning and has no parallels

• The levels of registration reflects the quality of governance.

Civil Registration System (CRS)- Scenario

• Registration of Births and Deaths in India is mandatory with the enactment of Registration of Births and Death Act (RBD Act), 1969.

• Registration of Births and Deaths falls under the Concurrent list of the Constitution.

• Registrar General, India unifies and coordinates the activities of the States.

• States are responsible for implementation of RBD Act.

• National Population Policy mandates cent percent registration.

• LOR (Birth) – India: 62.5% to 81.3 % ( + 18.8 %)

• LOR (Death)– India 55.0% to 66.9% ( + 11.9%)

• 13 States/UTs have achieved 100% registration

of births.

• 6 States/UTs have achieved 100% registration of

deaths.

• Some of the major States remains the main

concern.

Registration Scenario in India during last 5 years

Level of Registration of Births and Deaths, 2000-2009

Still every 5th birth & every 3rd death goes un-registered.

Issues Utility of birth and death certificate- Enhancing the utility

and awareness among the general public, a cause of

concern. States/UTs are functioning at different level of efficiency-

reflects the governance. Flow of registered vital events- a bottleneck in monitoring. Under reporting of domiciliary infant deaths & still births

and misclassification of maternal deaths in better

performing States- how to estimate IMR & MMR? Utility of data gets diminished on account of delayed

reporting by the States.

Initiatives to re-vitalise the system To enhance the utility, MOHFW has linked the delivery of

services with registration e.g. cash incentive under JSY etc. Provision for incentive to the States and to grass-root

workers Anganwadi/ASHA for registration and delivery.

Ministry of Health has made registration as one of the focus areas under National Rural Health Mission (NRHM)/ NHM.

To cover all institutional events, a database of Medical Institutions is being prepared.

Provisions of the Act are being simplified for better implementation.

Linking CRS at sub-district level to update NPR.

Collaboration with various partners for further strengthening of the system.

Introduced in early 1970s to provide cause-specific mortality profile.

Restricted to urban areas, that too few selected hospitals.

At various stages of implementation across different States.

Coding is as per ICD-10.

Covers about 19% of the total registered deaths only.

Garbage codes(R00-R99) are to the tune of 14%.

Medical Certification of Causes of Death (MCCD)

Time Series on Medically Certified Deaths vis-a-vis Total Registered Deaths Reported for the Period 1986-2007

ORGI has expanded the scope under MCCD to all Institutions including individual practitioners and the coverage , extended to rural areas as well.

Sample Registration System Genesis

Initiated in 1969-70 for want of complete registration from CRS.

Objectives Provide reliable annual estimates of birth, death and infant mortality rates

at the State and National levels separately for rural and urban areas. Also provides Child Mortality Rate (CMR), Total Fertility Rate (TFR), Sex

Ratio at Birth and 0-4 age, Institutional deliveries, Medical Attention before death, etc.

Under 5 mortality rate also generated from 2008 annually.

Features

•One of the largest demographic household sample survey in the world

Sample size determination based on IMR Permissible level of RSE: 10% (bigger states) 1.3 million households and about 7 million population Only panel survey with dual recording Panel revised once in 10 years based on the latest available Census frame

• Of the 8 MDGs, IMR, U5MR and MMR are generated by SRS.

Goal No.

Goals IndicatorsTargets by 2015

4

Reduce infant mortality Infant Mortality Rate (IMR) 28

Reduce child mortality Under 5 Mortality Rate (U5MR) 42

5 Improve maternal health Maternal Mortality Ratio (MMR) 109

MILLENNIUM DEVELOPMENT GOALS(MDG)

• MMRatio measures number of women aged 15-49 years dying due to maternal causes per 1,00,000 live births.

• Decline in MMR estimates in 2007-09 over 2004-06: At the country level, it has declined to 212 from 254 (a fall of about

17%) It varies between 81 in the State of Kerala to 390 in Assam ( a variability

of 5 times).

• MDG target of 109 have been achieved by 3 States viz. Kerala, Tamil Nadu & Maharashtra.

• 4 States viz. Andhra Pradesh, West Bengal, Gujarat and Haryana are in closer proximity to achieving the MDG target.

MMR ESTIMATES 2007-09

TREND IN MMRatio- India

(2004-06)

2009

2007-09 SRS

212

56 000 (2007-09)

Region MMR Life time risk

% share of female Popln.

% to total maternal deaths

EAG states 308 1.1% 48.0 61.6

Southern states

127 0.3% 21.0 11.4

Other states 149 0.4% 31.0 27.0

India 212 0.6% 100 100

LEVELS OF MMRATIO BY REGIONS, 2007-09

½ of the female population of EAG States contributes about 2/3rd of Maternal Deaths.

Total Fertility Rate (TFR) BY RESIDENCE, 1990-2011

TFR for the country declined by 1.4 points (down by more than a child), rural TFR also by 1.4 points and urban TFR by 0.9 point over last 21 years.

ANNUAL HEALTH SURVEY- DISTRICT LEVEL MONITORING

“To yield a comprehensive, representative and reliable dataset on core vital indicators including composite ones like IMR, MMR and TFR along with their co-variates (process and outcome indicators) at the district level and map changes therein on an annual basis.”

OBJECTIVE OF AHS

Coverage : Annual Health Survey

Odisha

Chhattisgarh

J harkhandMadhya Pradesh

BiharAssamRajasthan

Uttar Pradesh

Uttarakhand

o AHS States constitute:• 48 percent of country’s Population• 59 percent of Births• 70 percent of Infant Deaths• 75 percent of Under 5 Deaths• 62 percent of Maternal Deaths

o Enable direct monitoring of UN Millennium Development Goals on Child Mortality and Maternal Health at the district(s) level.

o Help in identifying high focus districts meriting special attention in view of stark inter-district variations in these States.

WHY AHS ?

• Panel Survey on the pattern of SRS.

• Coverage- All the 284 districts of 8 EAG States and Assam.

• Sample Size- IMR as the decisive indicator with 10%RSE.

• Sample Units- 20,694 statistically selected sample unit (Census Enumeration Blocks in urban areas and Villages or a part thereof in rural areas).

• Sample Population- About 20.1 million.

• Sample Households - 4.1 million households.

• Sample Units per district- 73.

• Sample Population per district - About 71 thousand.

• Sample households per district - About 14.5 thousand.

The Largest Sample Survey in the World

KEY FEATURES

•In all, 161 indicators are available from AHS baseline: Fertility- 13 Sex Ratio- 3Marriage- 5 Mortality- 7Mother & Child Care- 63Ante Natal Care: 11 Delivery Care: 8Post Natal Care: 5 Janani Suraksha Yojana (JSY): 3Immunization: 8 Vitamin A & Iron Supplements: 2Birth Weight: 2 Childhood Disease: 6Birth Registration: 2 Breastfeeding & Supplementation: 12Awareness in Mothers: 4

Abortion- 6 Family Planning Practices- 15 Disability- 1 Morbidity- 19Personal Habits:adults-4 Housing & HH Characteristics- 13Others- 12

INDICATORS UNDER AHS

OrissaChhattisgarh

J harkhand

Madhya Pradesh

Bihar

AssamRajasthanUttar Pradesh

Uttarakhand

Infant Mortality RateTop 100 Districts in AHS States

Clinical, Anthropometric & Bio-Chemical Component

• CAB component of the AHS would provide district level data on the prevalence of the following in a selected sub-samples of households across all the AHS districts.

under and over nutrition, anaemia, hypertension, fasting glucose levels, andhousehold availability of iodised salt

POLICY IMPLICATIONS Policy needs particularly in respect of reliable and timely data

have undergone a paradigm shift since last 50 years.

State level estimates are used for both central as well as state level planning. Also for pop. Proj., life tables, IMR, MMR, HDI etc.

SRS was therefore designed as a stop-gap arrangement to bridge the data gap at national and state levels in view of an deficient CRS.

Non availability of district level estimates thwarted the need for sub-state level planning despite the recognition of the facts that state averages mask the reality.

AHS conclusively proved the above hypothesis and stressed the importance of identifying the hotspots (districts requiring special attention).

Availability of such a rich and comprehensive dataset would help in accessing the impact of various health interventions including those under NRHM/ NHM – JSY, SRB.

Estimates of IMR at district level and MMR for a group of districts would enable tracking of MDGs at below state level.

District level estimates would provide requisite inputs for better planning of health programmes and pave the way for evidence based intervention strategies.

Results of CAB on such a large sample would be available for the first time, could be used for appropriate interventions, examining cause & effect relationship etc.

POLICY IMPLICATIONS

There is no substitute for a complete Civil Registration System

Bulk of the above information particularly fertility and mortality indicators cross-classified by standard auxiliary variables can be made available for all the districts if there was a complete and up to date CRVS.

Universal coverage under CRS will yield meaningful information on sex-ratio at birth and still birth rate, which would help in mapping the effectiveness of PNDT Act.

For causes of death, this perhaps (MCCD) is the only solution.

The list is endless………

POLICY IMPLICATIONS

Thank You