Introduction

Background

The availability of continuous information on mortality and its distribution in a country is necessary for effective decision-making in health program planning and resource allocation. It is also required for the monitoring of the effectiveness of health programs in preventing premature deaths. However, low- and middle-income countries (LMICs), which bear the highest burden of preventable premature deaths, suffer a crucial lack of timely data on mortality and causes of death. Thus, they are unable to adequately make health planning decisions based on local and empirical mortality information.

Key Points:

  • A sample registration system (SRS) uses a similar sampling survey concept but establishes continuous collection of population, fertility and mortality data from small geographic areas, carefully selected to generate estimates that are representative at a desired domain such as national, provincial or district level.

  • An SRS can provide data that’s more complete than the data from civil registration and health systems and more timely than data from largescale household surveys.

  • An SRS can be designed to catalyze the rapid scale-up of Civil Registration and Vital Statistics in high mortality countries.

Government data systems such as the civil registration and vital statistics (CRVS) and the routine health information system (RHIS) offer promising solutions, but their current mortality deficiencies are enormous and structural, and it will take decades to address them. CRVS suffers severe coverage and event registration incompleteness. RHIS captures only facility users, and deaths are not completely recorded and reported or always certified with cause of death. A feature of these systems, which is also their main challenge, is their exhaustivity mandate, that is their legal and ethical requirement to cover the entire population of the country.

To circumvent the challenges with CRVS and RHIS, countries usually implement national household sample surveys. The survey approach has been very beneficial and contributed substantially to advances in health programming and monitoring. However, surveys are irregular, short-term, and do not produce the recent data and disaggregation needed by these countries, specifically for outcomes such as mortality and health status. While they are effective at addressing specific health questions in specific populations and must continue and be improved on, they are not the most effective at continuous mortality monitoring.

A sample registration system (SRS) uses a similar sampling survey concept but establishes continuous collection of population, fertility and mortality data from small geographic areas, carefully selected to generate estimates that are representative at a desired domain such as national, provincial or district. An SRS does not register events legally, nor does it aim to cover the entire population. It is a vital statistics approach that collects and analyzes mortality and other population data to generate regular empirical estimates that are used for health monitoring. It can however facilitate registration of events within its coverage areas by linking to a CRVS system where events identified are transferred and registered. It can help catalyze the rapid scale-up of the CRVS system by not only linking the data but evaluating the completeness and quality of information from the CRVS system. Strategies that would build on an SRS to improve the completeness of CRVS are yet to be demonstrated. SRS have been implemented in many countries, including India1, Bangladesh2, Indonesia3, Vietnam4, and China5.

The experience in Africa is limited to one trial in Tanzania6 and recent launches in Mozambique and Sierra Leone.7,8

Recognizing the essential need for African countries to establish and strengthen systems to monitor mortality, the Africa Centers for Disease Control and Prevention (Africa CDC) developed, through consultation with its member States and experts, a continental framework for strengthening mortality surveillance in Africa, launched in September 2022.9 The framework represents an initial overall guidance document for countries in developing a strong mortality surveillance system that is based on a well-coordinated and integrated approach and aimed to harmonize all existing mortality data systems, standardize existing processes for data collection, analysis and dissemination, and standardizing mechanisms for death reporting that is aligned with the CRVS. Countries will still need practical manuals on the implementation of specific surveillance approaches. These operational manuals are under development by Africa CDC. Building on this momentum, the World Health Organization has also initiated the development of guidance materials for integrated mortality surveillance. While these efforts are critically needed to fill the mortality monitoring literacy gaps in LMICs, concrete steps toward systems that can generate reliable data in the short run are yet to be widely published.

Located in Eastern African, Mozambique launched an SRS in 2017 with financial support from the Bill & Melinda Gates Foundation (BMGF) and technical assistance from the Johns Hopkins Bloomberg School of Public Health. The SRS was initially implemented jointly by the National Institute of Health (INS) and the National Institute of Statistics (INE), but transitioned to INS leadership since 2021, with financial support from the Global Fund. It was initially called “Countrywide Mortality Surveillance for Action – COMSA” and later rebranded as “Sistema Comunitário de Vigilância em Saúde e de Eventos Vitais (Sis-COVE)” (Community Surveillance System for health and Vital Events). A similar investment was also implemented in Sierra Leone, in West Africa, since 2018 with technical assistance from the University of Toronto and implemented locally by the Ministry of Health, in collaboration with the Njala University.

This manual describes key steps and resources needed for the implementation of an SRS by an LMIC, building on the experience from Mozambique. It is developed as a practical resource with step-by-step guidance for countries and institutions interested in implementing an SRS for mortality surveillance. Supplementary materials are developed and made available to support each step. These materials are provided are samples or templates for adaptation and customization based on the country context and the objectives of the SRS.

The manual is based on twelve key steps for building and making functional an SRS, going from the initial conception to the full implementation and dissemination of the results. These twelve steps are organized within seven key phases that define the life-cycle of an SRS system.

To Learn More:

  1. http://censusindia.gov.in/vital_statistics/SRS/Sample_Registration_System.aspx ↩

  2. Bangladesh Bureau of Statistics (BBS). Report of Bangladesh Sample Vital Statistics 2018. Dhaka, Bangladesh, May 2019. www.bbs.gov.bd ↩

  3. Usman Y, Iriawan RW, Rosita T, Lusiana M, Kosen S, Kelly M et al. Indonesia’s sample registration system in 2018: a work in progress. Journal of Population and Social Studies. Vol 27 No. 1, 2019: January – March, DOI: 10.25133/JPSSv27n1.003 ↩

  4. Hoa NP, Rao C, Hoy DG, Hinh ND, Chuc NTK, Ngo DA. Mortality measures from sample-based surveillance: evidence of the epidemiological transition in Viet Nam. Bull World Health Organ 2012;90:764–772; doi:10.2471/BLT.11.100750 ↩

  5. Liu S, Wu X, Lopez AD et al. An integrated national mortality surveillance system for death registration and mortality surveillance, China. Bull World Health Organ 2016;94:46–57;doi:http://dx.doi.org/10.2471/BLT.15.153148 ↩

  6. Kabadi GS, Geubbels E, Lyatuu I, et al. Data resource profile: the sentinel panel of districts: tanzania’s national platform for health impact evaluation. Int J Epidemiol. 2015;44:79–86 ↩

  7. Amouzou A, Kante A, Macicame I, Antonio A, Gudo E, Duce P, Black RE. National sample vital registration system: a sustainable platform for COVID-19 and other infection disease surveillance in low and middle income countries. Journal of Global Health, December 2020, Vol. 10 No. 2. 020368; doi: 10.7189/jogh.10.020368 ↩

  8. Carshon-Marsh R, Aimone A, Ansumana R, Swaray IB, Assalif A, Musa A et al. Child, maternal, and adult mortality in Sierra Leone: nationally representative mortality survey 2018–20, Lancet Glob Health 2021, published Online November 25, 2021 doi:https://doi.org/10.1016/s2214-109x(21)00459-9 ↩

  9. Africa CDC. Continental Framework. Strengthening mortality surveillance systems in Africa. July 2023. https://africacdc.org/download/continental-framework-on-strengthening-mortality-surveillance-systems-in-africa/ (accessed November 12, 2023); See press release for the launch at https://africacdc.org/news-item/strengthening-mortality-surveillance-in-africa-africa-cdc-launches-continental-framework-document-to-support-member-states/ (accessed January 2, 2023) ↩

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