1Session 2: Different Perspectives of CRVS -- CRVS and HealthProfessor Dr Abul Kalam AzadAdditional Director General & Director, Management Information SystemDirectorate General of Health Services, MOHFW, BangladeshChair and distinguished participants,I am sure that all of you understand importance ofCRVS System very well.I shall tell you from personal experience -- why CRVSSystem matters for health.Then I shall tell you -- why health matters for CRVS.However, I mean a CRVS System -- that iselectronically maintained.Let me tell first -- how CRVS can benefit healthHere I shall make 6 points from experience:1. Communicable Disease Surveillance-- why we willcollect same demographic data every time?2. Routine immunization -- poor estimation of numberof children causes wastage of resource or poorprotection of children.3. Two MMR Surveys in Bangladesh -- we missedUN-MDG5 Award.4. Want to know MDG 4 & 5 status real time.5. Routine facility MCH data 2011 -- what ishappening in the community?6. Causes of death data -- we do not know for whatcauses most people are dying.To resolve problem -- MOHFWstarted population EHRprogram in its own way -- to create statistical evidence.
2CRVS systematic assessment -- new lessonsRecently we understood very hard facts fromsystematic CRVS assessment.Thanks to the UN ESCAP and WHO-SEARO forassistance.We observed -- fragmented efforts -- inefficient --unproductive -- non-standard system -- wastage ofresource.The gaps:1. The births & death registration project -- onlyinterested to register and issue birth and deathcertificates;2. The Election Commission -- interested only aboutvoters;3. The NSO -- collects 10 CRVS data elements -- butonly in sentinel sites -- and cause of death data notaccording to ICD-10;4. The MOHFW -- started EHR project -- but not forissuing legal birth or death registration certificate;5. None of the system is designed in standard way --and is not inter-operable.Now let me tell you -- why without health -- effectiveCRVS may not be possible -- this observation came fromour CRVS assessment1. The birth & death registration project -- will wait say 100years after registering birth for the death to occur -- notinterested to know cause of death;2. The election commission will only search a voter every4 or 5 years to update voter list;3. The NSO does not have enough staff for universal civilregistration -- the NSO is non-professional to determinecause of death;
34. Only MOHFW has responsibility and universal contactwith citizens through life course -- in fact -- it doesrequire more CRVS data than others -- it does collectalso more CRVS data than other.New strategy from lessons of CRVS Assessment1. We agreed to establish a common -- full coverage --standard --interoperable -- and -- sharable CRVSsystem -- together by all stakeholders - public, privateand DPs.We have a good start -- The COIA interventionConclusion
4IEDCR experience of Communicable DiseaseSurveillanceYear 2004 -- I took the responsibility of Director ofIEDCR.We were confronted with risk of rapid global spread ofemerging and re-emerging communicable diseases --like SARS, Bird flu, Nipah virus infection, etc.My institute was under pressure to build a functionaland responsive surveillance system to help forecasting,rapidly investigating and interveningsudden outbreak ofany communicable disease.You can imagine, in a country of 150 million population,mostly rural with not so advanced society, this wasreally a difficult task.When surveillance means -- collecting data onrespondents at intervals, the most obvious questioncame.Why should we write the name, age and sex of therespondents, every time?These are static data.As alternate, we can make acitizens’ registry with unique ID, name, date of birth andsex information, etc.An electronically maintained CRVS System can helpavoid this repetitive task, and save valuable staff timefor other priority and productive work.Wastage of resource in child immunizationThe second problem our ministry of health usually faces.Bangladesh is a successful country in universal routinechild immunization.However, in no year, we can accurately estimate howmany doses of vaccines we would need.
5Because we exactly do not know how many childrenpopulation we may have in any -- Because we don’thave mechanism to know population denominator otherthan census year.In non-census years, we estimate target population sizeby adjusting year-wise population growth rate byadjusting with census year’s population -- and in doingso, we use same population growth rate for all regionsof the country.It means, either weover-estimate or underestimatechildren’s number.And so we buy vaccine doses either in excess or lessthan needed.Excess means we waste money -- Less means, wekeep some children unprotected.A good CRVS System could help better manage thesituation.MMR Survey -- Bangladesh missed UN-MDG5 AwardThe immediately past two maternal mortality surveys ofBangladesh were done in 2001 and 2010 respectivelywith a 10 years’ interval in between.In 2001, the MMR was 320 per 100,000 live births.Even immediately before release of 2010 survey reportthere was a widespread assumption that the currentfigure should be above 290 per 100,000 live births --because we had no idea that our maternal healthinterventions were working.Surprisingly enough, the 2010 survey showed it to be194 per 100,000 live births.Just prior to release of the 2010 report, Bangladeshreceived MDG 4 award from the UN; but missed theMDG 5 award, which was given to Nepal.
6But, after release of our 2010 MMR report, weunderstood that our maternal health situation was muchbetter than in Nepal.We missed the MDG 5 award because we did not havean effective CRVS System.Bangladesh wants to MDG 4 & 5 status real timeBangladesh seriously wants to achieve MDGs 4 & 5.The country also believes that it would be possible.But, we want to know on real time -- how theinterventions are working.An electronic CRVS System integrated with HIS is thebest answer.And experts have identified that 42 MDG indicators outof 60 can be derived from CRVS data.Routine facility data on child deliveries & IMCIIn 2011, my department collected routine data on about0.6 million institutional deliveries.But, we do not know from these data how manydeliveries were taken place in the whole country thatyear -- or what was the institutional or home deliveryrates or national skilled birth attendance rate.Similarly, in 2011, we collected routine data on 25millionU5 children treated for IMCI diseases in healthfacilities.But, these huge data could not tell us was theprevalence of those diseases among U5 children.We do not know for what causes most people dieRecently, we started collecting causes of death data aswell as morbidity data from health facilities according toICD-10.But, more than 90% of deaths in Bangladesh occurshomes.
7Unless unnatural, these deaths do not require anymedical certification or need for finding cause of deathfor burial or for any other purpose.If we don’t know why most people die, or what are mostcommon disease burdens -- then how can we plan forpreventing unwanted or premature deaths -- or makinghospitals -- or creating human resource?MOHFW’s population EHRs to create statisticalevidenceMOHFW wanted to have a better solution to all theseproblems.So, the ministry started making a population healthregistry.The work began in 2009 and we collected data on 120million citizens out of 150 million.The data are now being fed into electronic database todevelop into EHRs and to be accessible across thecountry through electronic devices like computers,laptops, tablets in health facilities and community healthworkers.The preparation for this gigantic vision is also movingsatisfactorily.The whole idea is to have reliable and representativestatistics available real time to generate evidence andmake plans and decisions based on actual situation andthereby also minimize need of costly and timeconsuming common population surveys.CRVS systematic assessment -- new lessonsRecently we understood very hard facts.Thanks to the UN ESCAP and WHO-SEARO that thesetwo organizations assisted us in conducting rapid andthe comprehensive systematic assessment of ourCRVS System.
8These assessments provided us clear lessons that nosilo effort by any individual stakeholder ministry oragency will, in itself, be complete and fulfilling.We have explored -- how injudiciously, scarceresources are about to be inefficiently used.We identified number of gaps:6. The MOLGRDC has a National Birth & DeathRegistration Project supported by UNICEF, whichregisters only live births -- no still births -- and deathswithout causes of death; the project has beendesigned only to issue legal birth and deathregistration certificate -- and not for generatestatistical evidence;7. The National Election Commission, registers onlycitizens eligible for voting, i.e., citizens 18 years andabove;8. The National Statistics Office collects data on 10variables of CRVS, viz., birth, death, cause of deathnot according to ICD-10, marriage, divorce,immigration, emigration, etc.; but only from 1,000primary sampling sentinel sites -- unable to representcountry; and9. The MOHFW is interested for preparing electronichealth record -- not for other issues like issuing legalbirth or death registration certificate.The CRVS assessmentidentified that none of thesystem, either individually or collectively is designed inproper way.All the systems have been designed as stand-alonewithout intention to mutually benefit each other.And will not serve whole range of purpose of CRVSsystem.Many pertinent observations from CRVS assessment
95. The birth & death registration project is interested toknow about a citizen only after birth and then may beafter 100 year when the person will die; and is notinterested to know with what causes the person hasdied;6. The election commission is interested to know about acitizen only during election --to know whether or nots/he is eligible for voting or if registered, whether or notsurviving during the next election;7. The national statistics office has no ability to fulfilluniversal coverage of civil registration -- does notrecord death according to ICD -- and also have noauthority to issue legal birth or death registrationcertificate;8. The MOHFW, does not have mandate for issuing legalbirth and death certificate;But, due to having wider health service network andopportunity to access citizens throughout the lifecycle; andDue to relevance of all data parameters of CRVSSystem with health for understanding an individual’sor overall community or national health status;The MOHFW in its own right deserve engagement inthe national CRVS System as a core stakeholder --but not excluding others.Consensus for building national CRVS System ascommon sharable resourceBangladesh has great learning from the assessment ofCRVS SystemFrom this lesson, we built the consensus that all thestakeholders in Bangladesh will work together for anintegrated, shared, standard and inter-operableelectronic system.A good start -- COIA intervention
10We have started an intervention for COIA CountryFramework to institutionalize a community based Monitor-Review-Act cycle for improving maternal and child healthsituation in each small community of the country.ConclusionI believe that these example will help us how to build aneffective CRVS System and as a result will produce morehealth for money.Thank you.