Getting it Right on the Facts of Death: Initial Achievements and Challenges of the Implementation of Verbal Autopsy in Malaysia
1. Getting it Right on the Facts of Death:
Initial Achievements and Challenges of the
Implementation of Verbal Autopsy in
Malaysia
Arunah Chandran1, Nor Saleha Ibrahim Tamin1, Maimunah A Rahman2 , Feisul Mustapha1
1Disease Control Division, Ministry of Health Malaysia
2Health Informatics Centre, Ministry of Health Malaysia
9th National Public Health Conference
July 2018
2. Introduction: Verbal Autopsy (VA)
• Only 51.2% of deaths in Malaysia are
medically certified (1).
• In 2017, Ministry of Health (MOH) initiated
a system called “Verification of Non-
Medically Certified Death Data in
Malaysia” @ Verbal Autopsy (VA) to
improve mortality statistics in the country.
• Data derived from VA will be used for
health planning, priority setting,
monitoring and evaluation of health status
of the population (2).
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3. Introduction: Process of VA
• Non-medically certified deaths data are collected
monthly by National Registration Department (NRD) and
sent to MOH
• Health Informatics Centre (HIC) at the MOH sorts data by
districts and sends to respective states via NCD Section of
MOH HQ
• District assigns deaths to health clinics and health care
workers conduct VA via a WHO certified questionnaire
• Information is sent to HIC via State Health Departments
• HIC assigns cause of death (ICD-10) and data is sent to
Department of Statistics (DOS) for a more accurate
mortality statistics
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4. Objective of Review
• To examine the achievements of the VA system since its initiation
• Proportion of cases that failed to be medically certified
• Reasons for these failures
• To examine challenges faced by healthcare providers in the implementation
of VA
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5. Findings from VA
• From 1st October till 31st
December 2017, a total of
23,415 of non-medically
certified deaths were
notified by the National
Registration Department.
• Of these, approximately only
45% of the cases were
successfully medically
certified by healthcare
workers
5
Medically Certified
45%
Untraceable
due to wrong/
incomplete
address
12%
Refused to be interviewed
6%
Undetermined
9%
Uninvestigated
28%
6. The factors associated with failure to medically
certify deaths
• Socio-cultural
• Death and Disease Sensitivity
• Bereavement process
• Emotional stress to bereaved next of kin.
• Language
• Ethical
• Potential misallocation of limited resources
• Inadequately trained healthcare workers for counselling and bereavement process
• Administrative
• Delay in transfer of information through various departments leading to longer recall
period for respondents
• Incomplete demographic information available to interviewers ( contact details not
updated)
• Legal
• No legal measures compelling next of kin to provide information
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7. Important Lessons Learnt
• Consideration of cultural bereavement practices is important for
acceptance and improve response rates to VA
• Timing of verbal autopsy interviews.
“We went to interview the next of kin 3 months after the death and we were asked why
we came so long after a death. Causing them to remember the pain all over again”-
Medical Officer, Health Clinic KJ, District P
• Soft skills of interviewers is important for better outcomes of VA
• Training and periodic assessment of impact (mental and emotional stress)
on healthcare workers
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8. Discussion
• In the absence of a legal method to respond to VA ( e.g. as a pre-requisite to
receive a death certificate), there would be challenges in achieving high response
rates.
• Understanding these challenges is important to enable MOH and other
stakeholders to innovate solutions to further strengthen the system.
• It is important that experiences in various settings are reported as a critical
contribution to understanding of and refining VA methods.
• Implementation of VA can be improvised with an IT-based system leading to a
short recall and turnover time, improve data security and reduce errors
• VA is NOT for integration with the civil registries and provide the evidence for
legal death documentation (death certificates, insurance pay-outs, etc.).
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9. References
1. Statistics of Causes of Death Malaysia 2017 [press release]. 2017.
2. World Health Organization. Verbal Autopsy: Current Practise and
Challenges. Bulletin of World Health Organization. 2006.
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The final fact of life is that when you die, a doctor is required to fill out your death certificate, specifying the cause of death.
Assigning a cause is more than an exercise in morbid curiosity. The certificate has important legal and social purposes for families, affecting health and finances.
For policy makers, the documents provide information to track national trends in diseases and form a basis for health spending priorities.
For researchers, the information is crucial to scientific studies.
Still, death certificate information is often flawed, and that misinformation can affect policy.
Cause-of-death data derived from verbal autopsy (VA) are increasingly used for health planning, priority setting, monitoring and evaluation in countries with incomplete or no vital registration systems.
This is the process of Verbal Autopsy in Malaysia.
When death occurs, next of kin are required to notify National Registration Dept to obtain death certificates for the deceased.
