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 http://crvsinnovations.net

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. 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) –
www.champshealth.org
© Bill & Melinda Gates Foundation | 2
COUNTRYWIDE MORTALITY SURVEILLANCE FOR ACTION
(COMSA)

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. • 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. 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. 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. 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. 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. 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. For more information, please contact kathryn.banke@gatesfoundation.org
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!