The Global Summit on CRVSCivil Registration System,Sample Registration System&Annual Health Survey :Issues and Policy UsesDR. R. C. SETHIFORMER ADDITIONAL REGISTRAR GENERAL, INDIAOffice of the Registrar General, India18-19thApril 2013
OVERVIEWCivil Registration System- Status, Challengesand InitiativesSample Registration System, 2011- KeyResultsAnnual Health Survey, 2009-2011- Highlightsof the baseline survey
Civil Registration System• Comprehensive and complete CRS has multi-facetedimplications on socio-economic development of a country.• A complete & up to date CRS can provide: Reliable Statistics on fertility & mortality at all level ofaggregations Almost on a real time basis which is not possible from anysample survey. Key for evidence based planning and has no parallels• The levels of registration reflects the quality ofgovernance.
Civil Registration System (CRS)- Scenario• Registration of Births and Deaths in India is mandatorywith the enactment of Registration of Births and DeathAct (RBD Act), 1969.• Registration of Births and Deaths falls under theConcurrent list of the Constitution.• Registrar General, India unifies and coordinates theactivities of the States.• States are responsible for implementation of RBD Act.• National Population Policy mandates cent percentregistration.
• 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% registrationof births.• 6 States/UTs have achieved 100% registration ofdeaths.• Some of the major States remains the mainconcern.Registration Scenario in India during last 5 years
Level of Registration of Births and Deaths, 2000-2009 Still every 5thbirth & every 3rddeath goes un-registered.
Issues Utility of birth and death certificate- Enhancing the utilityand awareness among the general public, a cause ofconcern. 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 birthsand misclassification of maternal deaths in betterperforming States- how to estimate IMR & MMR? Utility of data gets diminished on account of delayedreporting by the States.
Initiatives to re-vitalise the system To enhance the utility, MOHFW has linked the delivery ofservices with registration e.g. cash incentive under JSY etc. Provision for incentive to the States and to grass-rootworkers Anganwadi/ASHA for registration and delivery. Ministry of Health has made registration as one of the focusareas under National Rural Health Mission (NRHM)/ NHM. To cover all institutional events, a database of MedicalInstitutions is being prepared. Provisions of the Act are being simplified for betterimplementation. Linking CRS at sub-district level to update NPR. Collaboration with various partners for furtherstrengthening of the system.
Introduced in early 1970s to provide cause-specificmortality profile. Restricted to urban areas, that too few selectedhospitals. At various stages of implementation across differentStates. 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 Reportedfor the Period 1986-2007ORGI has expanded the scope under MCCD to all Institutionsincluding individual practitioners and the coverage , extendedto rural areas as well.
Sample Registration SystemGenesisInitiated in 1969-70 for want of complete registration from CRS.Objectives Provide reliable annual estimates of birth, death and infant mortality ratesat the State and National levels separately for rural and urban areas. Also provides Child Mortality Rate (CMR), Total Fertility Rate (TFR), SexRatio at Birth and 0-4 age, Institutional deliveries, Medical Attention beforedeath, 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.GoalNo.Goals IndicatorsTargetsby 20154Reduce infant mortality Infant Mortality Rate (IMR) 28Reduce child mortality Under 5 Mortality Rate (U5MR) 425 Improve maternal health Maternal Mortality Ratio (MMR) 109MILLENNIUM DEVELOPMENT GOALS(MDG)
• MMRatio measures number of women aged 15-49 years dyingdue 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 about17%) It varies between 81 in the State of Kerala to 390 in Assam ( a variabilityof 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 andHaryana are in closer proximity to achieving the MDG target.MMR ESTIMATES 2007-09
TREND IN MMRatio- India(2004-06)20092007-09 SRS21256 000(2007-09)
Region MMR Life timerisk% share offemale Popln.% to totalmaternal deathsEAG states 308 1.1% 48.0 61.6Southernstates127 0.3% 21.0 11.4Other states 149 0.4% 31.0 27.0India 212 0.6% 100 100LEVELS OF MMRATIO BY REGIONS, 2007-09 ½ of the female population of EAG States contributes about2/3rdof Maternal Deaths.
Total Fertility Rate (TFR) BY RESIDENCE, 1990-2011 TFR for the country declined by 1.4 points (down bymore than a child), rural TFR also by 1.4 points andurban TFR by 0.9 point over last 21 years.
ANNUAL HEALTH SURVEY-DISTRICT LEVEL MONITORING
“To yield a comprehensive,representative and reliable dataset oncore vital indicators includingcomposite ones like IMR, MMR andTFR along with their co-variates(process and outcome indicators) atthe district level and map changestherein on an annual basis.”OBJECTIVE OF AHS
Coverage : Annual Health SurveyOdishaChhattisgarhJharkhandMadhya PradeshBiharAssamRajasthanUttar PradeshUttarakhand
oAHS 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 DeathsoEnable direct monitoring of UN MillenniumDevelopment Goals on Child Mortality and MaternalHealth at the district(s) level.oHelp in identifying high focus districts meritingspecial attention in view of stark inter-districtvariations 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 apart 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 WorldKEY 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: 4Abortion- 6 Family Planning Practices- 15Disability- 1 Morbidity- 19Personal Habits:adults-4 Housing & HH Characteristics- 13Others- 12INDICATORS UNDER AHS
OrissaChhattisgarhJharkhandMadhya PradeshBiharAssamRajasthanUttar PradeshUttarakhandInfant Mortality RateTop 100 Districts in AHS States
Clinical, Anthropometric & Bio-Chemical Component• CAB component of the AHS would providedistrict level data on the prevalence of thefollowing in a selected sub-samples ofhouseholds 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 datahave undergone a paradigm shift since last 50 years. State level estimates are used for both central as well as statelevel planning. Also for pop. Proj., life tables, IMR, MMR, HDIetc. SRS was therefore designed as a stop-gap arrangement tobridge the data gap at national and state levels in view of andeficient CRS. Non availability of district level estimates thwarted the needfor sub-state level planning despite the recognition of thefacts that state averages mask the reality.
AHS conclusively proved the above hypothesis and stressedthe importance of identifying the hotspots (districtsrequiring special attention). Availability of such a rich and comprehensive dataset wouldhelp in accessing the impact of various health interventionsincluding those under NRHM/ NHM – JSY, SRB. Estimates of IMR at district level and MMR for a group ofdistricts would enable tracking of MDGs at below state level. District level estimates would provide requisite inputs forbetter planning of health programmes and pave the way forevidence based intervention strategies. Results of CAB on such a large sample would be availablefor the first time, could be used for appropriateinterventions, examining cause & effect relationship etc.POLICY IMPLICATIONS
There is no substitute for a completeCivil Registration System Bulk of the above information particularly fertility andmortality indicators cross-classified by standard auxiliaryvariables can be made available for all the districts if therewas a complete and up to date CRVS. Universal coverage under CRS will yield meaningfulinformation on sex-ratio at birth and still birth rate, whichwould help in mapping the effectiveness of PNDT Act. For causes of death, this perhaps (MCCD) is the onlysolution. The list is endless………POLICY IMPLICATIONS