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Scandal of invisibility plagues countries with no civil registries

Most people in Africa and Asia are born and die without leaving a trace in any official records, giving policymakers and researchers little information on which to base public health decisions, a University of North Carolina at Chapel Hill researcher and colleagues say in a paper published today (Oct. 29, 2007) in the British medical journal The Lancet.

However, affordable solutions exist to collect these vital statistics and must be implemented urgently to end what the study authors call a scandal of invisibility.

In the lead paper of The Lancets Who Counts series, produced in collaboration with the Health Metrics Network based at the World Health Organization, Philip Setel, Ph. D., and colleagues analyze the lack or inadequacy of civil registration systems for counting births, deaths and causes of death. Without these statistics, Setel said, officials can make only educated guesses based on models about the numbers of deaths due to various causes in their populations.

In their Lancet paper, titled A Scandal of Invisibility: Making Everyone Count by Counting Everyone, Setel, a research professor of epidemiology in UNCs School of Public Health, says that over the past 30 years there has been a persistent failure to establish, support and sustain civil registries and to ensure that causes of death are accurately known in the worlds poorest countries.

In sub-Saharan Africa fewer than 10 countries have routine vital statistics systems that produce usable data, and mortality data is reported from only four, Setel said. Reliable data on levels of adult death let alone causes of death simply do not exist for most countries in Africa and Asia, where a large majority of deaths occur at home.

International donors, including the United States, spent more than $80 billion in 2004 on overseas medical aid, yet there is no conclusive evidence that this money is making a difference in preventing deaths, including those from AIDS, tuberculosis and malaria. Until civil registration systems can be rebuilt, Setel said, other cost-effective interim measures must be taken.

Taking action now, says The Lancets editor Richard Horton, is nothing more than a test of our humanity.

Setel is also deputy director of the MEASURE Evaluation (Monitoring and Evaluation to Access and Use Results) Project at UNCs Carolina Population Center. The project, funded by the U.S. Agency for International Development (USAID), works with government ministries, institutions and communities around the world to strengthen each countrys ability to collect and use health data.

National authorities in Mozambique, for example, are conducting the worlds first post-census mortality survey using methods developed by MEASURE Evaluation and the U.S. Census Bureau. This cost-effective system, called Sample Vital Registration with Verbal Autopsy, or SAVVY, can provide an ongoing source of data on mortality and causes of death for countries in which they have never previously existed.

The SAVVY methods also can be used with other data collection activities. Mozambiques 2007 national census collected information on deaths within the last 12 months. Workers trained through SAVVY are currently are conducting a verbal autopsy, contacting people in these households, asking about signs and symptoms the deceased displayed before death with the hope that a reasonable cause of death can be determined.

When the survey is complete, Mozambique will know, for example, how many AIDS, malaria and maternal deaths occurred in the last year. This information will not only become the basis of national mortality statistics to be reported internationally, but will be used in benchmarking health Millennium Development Goals; serve as baselines for AIDS and malaria mortality early on in the massive scale-up of interventions; and allow Mozambique to produce an atlas of preventable mortality at the provincial level for use in examining overall national priorities and health inequalities.

The SAVVY resource library provides all the necessary reference materials to establish a complete system capable of generating nationally representative vital events information or strengthening existing sources of data. The materials are the result of extensive field application and expert review and are consistent with agreed international standards and best-practices.


Contact: Clinton Colmenares
University of North Carolina at Chapel Hill

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