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Countrywide mortality surveillance for action (COMSA): examples from the field


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Presentation by Kathryn Banke (BMGF) at the international conference on innovations in Civil Registration and Vital Statistics (CRVS) systems - Ottawa on 27-28 February 2018. See more at

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Countrywide mortality surveillance for action (COMSA): examples from the field

  1. 1. COUNTRYWIDE MORTALITY SURVEILLANCE FOR ACTION (COMSA): EXAMPLES FROM THE FIELD An enhanced sample registration system to build CRVS capacity in Mozambique and Sierra Leone © 2018 Bill & Melinda Gates Foundation International Conference on Innovations in CRVS Systems February 27, 2018
  2. 2. Nationally and subnationally representative enhanced sample registration system (SRS) tailored to country’s CRVS-strengthening plans and existing capacity Produce and make available continuous annual data on births, mortality, and cause of death at national and subnational levels for use by the government and stakeholders in health programs, policy decision-making, and resource allocation Incorporate focused minimally invasive tissue sampling (MITS) to adjust cause of death estimates from verbal autopsies for children under five years of age Child Health and Mortality Prevention Surveillance (CHAMPS) – © Bill & Melinda Gates Foundation | 2 COUNTRYWIDE MORTALITY SURVEILLANCE FOR ACTION (COMSA)
  3. 3. COMSA APPROACH Led by national statistics institutes with close collaboration from ministries of health, national civil registration authorities, national public health institutes • Three-four years of BMGF support for external technical assistance • Low running costs Select representative enumeration areas across a country • Cover ~ 3-8% of entire population • Identify, record, report pregnancies, births, and deaths • Conduct verbal autopsy (VA) on all deaths Perform MITS on a subset of approximately 200 deaths among children under 5 years Assemble all data across the country (VA, MITS from CHAMPS site and other) and calculate statistics at the national and provincial/regional levels • National and subnational crude birth and death rates • Age-group specific mortality rates and cause-specific mortality fraction and rates • Validate VA results against MITS data and calibrate national cause of death data accordingly Integrate with existing data systems and share data promptly and continuously with local, national, and international stakeholders
  4. 4. • Vital events detected are translated into registrations and certifications - Integrate with e-CRVS systems and national CRVS plans - Raise local awareness and facilitate registration - Support training in coding and medical certification of cause of death and use of standard WHO death certificate for facility death reporting (integrated with DHIS2) • Functional SRS enumeration areas provide denominators and can expand to a comprehensive CRVS system • Health authorities as partners will use data to guide health policy • Link mortality data from facilities, integrated disease surveillance & response systems, and communities INTEGRATION WITH THE CRVS AND HEALTH SYSTEMS
  5. 5. 3 year grant (ends December 2019) Institute for International Programs – Johns Hopkins University Fixed sample of 700 EAs (~300 households each) • Community surveillance agents (CSA) list households and record pregnancies, outcomes, and deaths • Provincial teams conduct VAs for all deaths and supervise CSAs • Data feed into dashboard (feedback to provincial teams), public website for government and public visibility and use, DHIS2 Timeline • Verbal autopsy data collection starting in February in five phase I provinces • Data collection begins in remaining five provinces + Maputo mid-2018 • MITS on under five deaths from Zambezia province starting ~ mid-2018 © Bill & Melinda Gates Foundation | 5 COMSA MOZAMBIQUE Phase 1 Phase 1 + MITS Phase 2 •900,000 population under surveillance •38,000 annual births •9,000 annual deaths •2,600 annual U5 deaths
  6. 6. DESIGNING COMSA MOZAMBIQUE TO STRENGTHEN CRVS 3. Currently under discussion with CRVS Unit 1. Assess compatibility between COMSA and CRVS data systems 2. Make COMSA data on births, deaths, and cause of death available to CRVS 3. CRVS will document accuracy of events 4. CRVS upload data into CRVS system and issue event certificate to the family Note: By law registration must be done by CRVS. COMSA cannot directly link its system to CRVS data system. Mozambique CRVS System1. SMS notification of births and deaths by CSAs to e-CRVS system and receipt of unique event ID issued by CRVS system (CRVS must approve the CSAs as notifiers) 2. Pilot electronic reporting by CSAs directly using CRVS birth and death forms in one province CSA Community Level COMSA Data System
  7. 7. 4 year grant (ends December 2021) Centre for Global Health Research 2018 a planning year with verbal autopsy data collection starting in early 2019 and MITS timing TBD Planned outputs by 2021: SRS covers ~1000 units with ~100,000 households, ~22,000 births, ~7500 deaths 12-15 personnel from Sierra Leone trained at U of Toronto and elsewhere to design/run/manage the SRS and use the data Two reports on national level child mortality (levels, district variation, and causes of death), two reports on maternal mortality (national), one report on adult causes of death Biological testing site in Bo District established (~200 with MITS) 200 field staff conducting routine surveillance nationally 60 doctors and nurses coding VAs (ICD-10) – part-time, dual coding with reconciliation 200 doctors/nurses certified to complete WHO facility death certificates Low-cost platforms that are sustainable through 2030, integrated with country CRVS priorities © Bill & Melinda Gates Foundation | 7 COMSA SIERRA LEONE
  8. 8. Support CRVS  Strengthen capabilities in birth/death registration  Assist NCRA plans  All Bo district health facilities use WHO death certificate for facility death reporting (integrated with DHIS2 software)  Facility death module turned over to DHIS2 to sustain Stronger evidence base for national programs  At least 4 MOHS working groups to link all available mortality and IDSR surveillance data for priority diseases (e.g. maternal mortality)  Sierra Leone-specific web portal to map/share ALL available mortality and disease data © Bill & Melinda Gates Foundation | 8 COMSA SIERRA LEONE
  9. 9. VISION FOR THE FUTURE • Demonstrate data to impact in three countries • Mozambique (January 2017 – December 2019) • Sierra Leone (November 2017 – December 2021) • Mali (TBD) • Fine-tune • Replicate in other countries • After initial BMGF support, continued funding by countries and/or development banks and other funders
  10. 10. For more information, please contact Special thanks to: Mozambique: National Institute of Statistics (INE), National Institute of Health (INS), Ministry of Health (MISAU), Ministry of Justice, CISM (Manhica) Sierra Leone: Statistics Sierra Leone, Ministry of Health and Sanitation, National Civil Registration Authority, CDC Sierra Leone Grantees: Institute for International Programs – Johns Hopkins University, Centre for Global Health Research © Bill & Melinda Gates Foundation | 10 THANK YOU!