Global congres va fatima marinho bali_feb_2011p_final

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Global congres va fatima marinho bali_feb_2011p_final

  1. 1. Verbal Autopsy Americas Integration into National Health Information System Global Congress on Verbal Autopsy: State of the Science 15-17 February, 2011, Bali, Indonesia Fatima Marinho MD, MPH, PhD Information and Health Analysis (HSD/HA) Pan American Health Organization (PAHO/WHO) [email_address]
  2. 2. Topics <ul><li>Information and Health Analysis (HA) goals </li></ul><ul><li>Mortality Data base </li></ul><ul><li>Quality of death information in The Americas </li></ul><ul><li>% under-registration, % ill defined, % garbage codes </li></ul><ul><li>Status and challenges </li></ul><ul><li>Countries experiences - Improving mortality data </li></ul><ul><li>Strategic Plan </li></ul><ul><li>Points for discussion </li></ul>
  3. 3. Goals <ul><li>Technical support to the countries to build capacity for data collection and analysis, </li></ul><ul><li>Technical support to the national decision-makers translate evidence into new policy directions, </li></ul><ul><li>Work directly with the countries to improve the Health Information System (HIS), </li></ul><ul><li>Collect, organize and validate the health information in the Americas, </li></ul><ul><li>Provide a good information, </li></ul><ul><li>Make analysis of the health situation, health determinants and others, </li></ul><ul><li>Monitoring the health situation. </li></ul>
  4. 4. <ul><li>Mortality Data </li></ul><ul><li>Main Variables/Annual data </li></ul><ul><li>requested to the countries * </li></ul><ul><li>Deaths: Individual data on each death, with the following specifications: </li></ul><ul><li>Sex </li></ul><ul><li>Underlying cause of death </li></ul><ul><li>Age (in hours for the first day, in days for the first month, in months for the first year, and in complete years after one year of age) </li></ul><ul><li>Other available causes </li></ul><ul><li>*Since 2009 this extensive set has been requested </li></ul><ul><li>Major civil division of residence of the decedent </li></ul><ul><li>Certification of the cause (s) of death: physician or nonmedical </li></ul><ul><li>Educational attainment of decedent (instruction or education level) </li></ul><ul><li>Ethnicity of the decedent </li></ul><ul><li>Place of occurrence of the death (hospital, residence, public thoroughfare, etc) </li></ul><ul><li> </li></ul>45/48 Countries and Territories in the Americas have a Vital Statistics System working
  5. 5. <ul><li>20% of the cause of deaths are “Garbage codes” </li></ul><ul><li>Intermediate causes </li></ul><ul><li>are the most important Garbage codes (44%) </li></ul>ill - defined and 10 causes accumulate 80% Source: PAHO/WHO. Mortality Information System; Washington DC:2010 As of February 9 2010 2.7 I51 Complications and ill-defined descriptions of heart disease 2.7 J96 Respiratory failure, not elsewhere classified 2.8 J69 Pneumonitis due to solids and liquids 3.2 N19 Unspecified renal failure 3.4 X59 Exposure to unspecified factor 5.2 C80 Malignant neoplasm without specification of site 5.4 N18 Chronic renal failure 6.1 I10 Essential (primary) hypertension 8.7 A41 Other septicaemia 17.3 I50 Heart failure       26.43 R00-R99 ill -defined       % ICD-10 Causes
  6. 6. Countries Experience Improving Mortality Data
  7. 7. Quantifying the coverage problem Setting Priorities In Brazil, coverage and quality are very good in the Southeast and South where 60% of the population live. In the Central West Region the coverage is 90%. 10% of the country’s population live in this region. Mortality Information System (SIM) Brazil
  8. 8. Quantifying the Quality Problem in Brazil Proportion of Ill-Defined causes of death, SIM   1996 1997 1998 1999 2000 2001 2002 2003 2004 BR 15 15 15 15 14 14 14 13 12 NO 24 24 24 24 24 23 22 21 21 NE 32 31 30 30 28 28 27 26 24 SE 9 9 10 10 10 10 9 9 8 SO 9 8 8 7 6 6 6 7 6 C W 11 11 11 11 9 8 7 6 6 Source: CGIAE/DASIS/SVS/MS Feb 2009
  9. 9. National Goals Diagnosis of cause of death: - increase to 90% Death registration system coverage: - increase to 90% in the Northeast Region How? 4- Systematic Search of under-registered deaths at the municipality level – Verbal Autopsy 5- Investigation of 100% of Ill-Defined cause of Death – Verbal Autopsy
  10. 10. Local Actions- Slicing the problem into small pieces <ul><li>Systematic search of burial places where people with no legal paperwork are buried </li></ul><ul><li>Systematic search for illegal cemeteries </li></ul><ul><li>Systematic search of deaths registered in the Civil Register office that are not part of the MoH mortality system </li></ul><ul><li>The MoH has started the organization of burials, working with the District Attorneys and communities </li></ul>
  11. 11. Ceará-Mirim – Municipality – rural area a very small piece of the problem 60,000 inhabitants – 21 cemetery – 19 illegal
  12. 12. Área de estudo State of Alagoas, Northern of Brazil-2004 Pop: 2,947,717 Mortality coverage: 66% Red and yellow areas are target areas A measure was developed to estimate the coverage in small cities
  13. 13. Fonte: Planilha de busca ativa Systematic Death Search Results, Alagoas, Brazil - 2005
  14. 14. <ul><li>Investigation tools have been developed </li></ul><ul><ul><li>Health Services </li></ul></ul><ul><ul><li>Record Linkage: hospital, surveillance, mortality data base </li></ul></ul><ul><ul><li>Verbal Autopsy </li></ul></ul>Actions at the local level- defining the cause of death Investigating the causes of death at the community level
  15. 15. Verbal Autopsy: Implementation <ul><li>To improve death investigation, the MoH team field-tested the verbal autopsy formulary (SAVVY) in a urban and rural area, partnering with MEASURE EVALUATION (2007) </li></ul><ul><li>First test: 12 formularies were applied, in a municipality – adjustment of the Mozambique formulary </li></ul><ul><li>Second test: 50 questionnaires applied, in different municipalities during a workshop with supervision of Measure Evaluation, one person from Mozambique and PAHO – 17 states representatives trained </li></ul><ul><li>Third test: in 17 states </li></ul><ul><li>Results: 1,238 deaths investigated </li></ul><ul><li>85% deaths w/underlying causes of death determined </li></ul><ul><li>Evaluation with the states and PAHO </li></ul><ul><li>          </li></ul>
  16. 16. Verbal Autopsy as Routine in the Mortality Information System <ul><li>Final version: Questionnaire implemented in the entire country in 2009 as a routine in the Mortality Information System </li></ul><ul><li>It is mandatory investigate: Maternal death, infant deaths, ill-defined cause of death and women death (age 10-49) </li></ul><ul><li>Search for NO-registered death </li></ul><ul><li>National Agreement Indicators </li></ul><ul><li>Who is applying the VA? </li></ul><ul><ul><li>Health community workers as part of the Family Health Program activities (1 team for 4500 people) </li></ul></ul><ul><ul><li>1 team: 1 doctor, 1 nurse (university degree), 3 nurses assistants, and 5 community workers </li></ul></ul><ul><li>The diagnose and death certificate are filled out and signed by primary care doctors </li></ul><ul><li>System: Codification and incorporation in the national system (there is a variable identifying the cause of death as a result of investigation) </li></ul>
  17. 17. Research of the underlying cause of death Analysis of Health Information System Verbal Autopsy - Pilot Test - Paraguay 2010 <ul><li>Proposed PAHO/WHO and MoH, to implement a pilot test of the Verbal Autopsy (based in Brazilian experience) </li></ul><ul><li>Regional Plan Strengthening Vital and Health Statistics (component of quality of data) </li></ul><ul><li>- Analysis of % ill defined causes of death (mortality database September-December 2009) by departaments </li></ul><ul><li>Selection of the district: Regional Hospital Luque- Reference Center </li></ul><ul><li>- Review, translation and adaptation of tools (Brazil) </li></ul><ul><li>Approval of local authorities </li></ul><ul><li>Mapping the area </li></ul><ul><li>Training: interviewers and certifying physician </li></ul><ul><li>Pilot test: April with support of PAHO/WHO - HA </li></ul><ul><li>Well accepted by the population, interviewers and hospital medical team </li></ul><ul><li>Documentation and revision of each case by physicians team </li></ul><ul><li>Reviewing and coding of all deaths by coders and physician </li></ul><ul><li>Reclassification of ill defined causes of death </li></ul><ul><li>Presentation and discussion of results to all staff of the hospital and the area selected for the pilot test </li></ul><ul><li>Discussion on the advantages of the use of verbal autopsy with the Minister of Health </li></ul><ul><li>Next Step </li></ul><ul><li>- To establish a working group in order to implement the use of verbal autopsy as one of the alternatives for improving the quality of mortality information </li></ul>Results
  18. 18. Points for Discussion <ul><li>Why are Countries not investigating ill-defined causes of death? </li></ul><ul><ul><li>The main problem is the absence of a operational proposal (how to do) </li></ul></ul><ul><ul><li>There is a perception that it is too difficult to improve the coverage and quality of mortality information </li></ul></ul><ul><ul><li>There is a believe that vital statistics will improve naturally or improve with the natural history of the vital statistics information system </li></ul></ul><ul><li>Fact: It is possible to make a good project with little budget </li></ul><ul><li>The most important tangible and sustainable impact will be reached when the project promotes strategies at the local level, and activities that address the problem where it is produced/originated </li></ul><ul><li>Political commitment </li></ul><ul><li>Challenges </li></ul><ul><li> - Change Behaviors related to produce and use of the </li></ul><ul><li>information in the countries </li></ul><ul><ul><li>Change the UN </li></ul></ul><ul><ul><li>Get financial support to go on with the project </li></ul></ul>

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