Ten Critical Milestones For A Strong CRVS System In Myanmar Khin - - PDF document

Ten Critical Milestones For A Strong CRVS System In Myanmar

Khin Sandar Bo, Joan Sarah Thomas, Alan D Lopez Abstract In recent years, Myanmar has made substantial progress in improving its CRVS

• system. Under the Bloomberg Philanthropies Data for Health (D4H) Initiative, an evaluation
• f the existing civil registration and vital statistics (CRVS) system was conducted including

qualitative and secondary quantitative data analysis to prepare for an innovative program of strategic CRVS improvement activities. Ten critical milestones were mapped against Myanmar’s current CRVS system using business process mapping. Four critical steps do not currently exist in the system including: lack of proactive notification of births and deaths; data validation; sharing of individual records with key government agencies; and quality assurance. The other 6 milestones, although present, are in need of strengthening due to the low coverage of death registration, poor quality of COD data, age heaping and critical errors in COD medical certification practices. In collaboration with the government of Myanmar, the D4H Initiative is implementing a set of targeted interventions aimed at strengthening the CRVS system, including verbal autopsy, an innovation to improve information on causes of community deaths. Myanmar will also work with technical experts to improve capacities for coding, certification of COD and the calculation of completeness of the registration. The curriculum of the VA and COD medical certification will be embedded in medical students and basic health staff courses for sustainable manner. Background Real-time and accurate births and deaths data are crucial in development of national health and population policies. Especially, complete and reliable mortality statistic and cause

• f deaths (COD) information are essential for drawing national health planning and to

response the emerging health issues and epidemic by timely manner. The registration of births and deaths, including the accurate cause of death information, has become the fundamental of improving public health system and save lives.

In most countries, the vital events, including births and deaths, are used to record through government’s Civil Registration and Vital Statistics (CRVS) systems. Globally, approximately 65% of all deaths (about 35 million) each year is found as unrecorded and more than 80% of deaths do not provide medically accurate or specific COD information. Subsequently, government officials, public health leaders and donors have difficulties to make informed decisions on priorities issues and resources allocation. Despite of that, there has a particular concern on monitoring and measuring the Sustainable Development Goals. The CRVS system of Myanmar was established in lower townships of Myanmar in late nineteenth century, and extended to upper Myanmar in 1906 and 1907 (2). National representative registration system was started in 1984. Legislation in Myanmar since 2012

• bligates families to report births and deaths within 3 days (3). During 20th century, Myanmar

has growing momentum in its civil registration vital system (CRVS). However, an assessment of Myanmar’s CRVS system gave it a vital statistical performance index (VSPI) score of under 0.5 score (4). This score was largely driven by low levels of completeness, accuracy, and quality of death reporting as well as inaccuracies in age reporting due to age-heaping. Capture of relevant information on causes of home deaths was inadequate and timeliness of reporting was also considerable issue in Myanmar(4). Further studies were identified as pre-requisites to better understand the CRVS structure, processes, workflows, systems and policies and to investigate weakness of the system such as overlaps, duplication, delays, data and data quality occur. Evaluation on the CRVS system in Myanmar In 2015, the Government of Myanmar in collaboration with the Bloomberg Philanthropies Data for Health (D4H) Initiative officially committed to strategically strengthen its CRVS system. As part of the initiative, a series of analysis were undertaken to evaluate the existing civil registration and vital statistics (CRVS) system from January to August of 2016. The expected outcomes of the baseline evaluation were to explore key stakeholders of the CRVS process, to assess the Knowledge, Attitude, Practices of the key stakeholders and community, to investigate major weakness in data collection and transfer process at various levels and to find out the appropriate ways for adapting innovative strategic interventions to improve the CRVS system. These findings will enhance the feasibility of the D4H for the Myanmar context.

The evaluation was a cross-sectional study design which is useful to evaluate the vital registration procedures, redefine the broader strategies of the D4H, appropriate technology to improve the function of the whole CRVS system(5). In additional, the design includes the feasibility assessment to explore at the possible benefits, threats and costs of innovation activities, an adaptation to an innovation technology and integration in the existing CRVS system(5). Evaluation Framework and Principles of Enterprise Architecture The nature of CRVS system is extraordinary complex because countries have different organization, process, policies and partners in their CRVS system. The system also involves numerous stakeholders at different level; shares accountability between multiple sectors and ministries to achieve same outputs; and requires unique ways in response to different political, legal, historical and administrative contexts. Despite of that, low- and middle-income countries have challenges in strengthening the CRVS system and to achieve adequate levels of coverage and quality. To improve the overall performance of the CRVS system rapidly and sustainably, a system thinking approach is critical to use apart from providing necessary technical support. The rational for using the system thinking approach are to understand how the various elements of the CRVS system are connected to each other and how they need to work together within the whole. Thus, the principle of Enterprise Architecture (EA): business process mapping method is applied in constructing the evaluation framework of the baseline evaluation of the CRVS system in Myanmar. Applying this innovative EA framework allows a systematic review and thinking to better understand how to most effectively implement CRVS improvement activities under the D4H Initiative in a strategic and effective way. Two types of descriptive process mappings: the stakeholder’s relation map and the process map, were done against with the CRVS system of Myanmar. These maps can be used to systematically monitor change due to implementation of improvement activities over time. Roles of the CRVS Stakeholders in Myanmar The CRVS stakeholders’ workshops were organized in Jan and May and August

• 2016. The stakeholder relationship map was drawn to describe all government agencies,

funding partners, suppliers, offices, users at various levels of the system and show the part-to-

whole relationships, connections, and linkage. The CRVS stakeholders in Myanmar are described detailed in the following figure (1):

Figure (1) - The stakeholders relation map: the CRVS stakeholders in Myanmar

The main institutions responsible for the Myanmar CRVS system are Ministry of Health and Sports (MOHS) and Central Statistical Organization (CSO). The Civil Registration of birth and death are conducted by basic health staff and doctors under the authority of the MOHS. Birth certificates, death certificates and burial certificates are issued by Township Medical Officers. Vital registration statistics are sent to the Central Statistics Organization (CSO), Ministry of Planning and Finance, for tabulation, analysis and publishing the reports. Ward/Village general administrators (GAD) under Ministry of Home Affairs (MOHA) also collect the birth and death data for general administration purposes and to issue National Registration Cards (NRC) jointly with Department of Population and Immigration. The burial permission tickets are issued by municipal department with recommendation of ward/ village general administrators and show the burial certificates. However, there is weak collaboration among related departments and CRVS stakeholders at different level and there is discrepancy in total registration data between the parallel data collection system. A national level Coordination Committee on Birth and Death Registration (CCBDR) was reformed in 2016 and chaired by the Union Minister of Ministry of Health and Sports. Director Generals from 13 concerned ministries participate in this committee. The committee

provides strategic directions and higher level decision in improving the CRVS system in Myanmar and focused on increase coverage and coordination among departments. An Internal Agency Working Group (IAWG) for Vital Registration, consisting of technical officials from key government departments, was formed in 2006 to facilitate close collaboration among CRVS stakeholders and to improve coverage of birth and death

• registration. Representatives from the Department of Public Health (MOHS), CSO,

Department of General Administration (GAD), Department of Population and Immigration, Department of Social Welfare (DSW), Department of Human Resource and Education Planning and UNICEF participate in this working group. Process and Workflow of CRVS system in Myanmar Ten critical milestones were identified and mapped against Myanmar’s current CRVS workflow by innovatively applying the EA. The business process map helps to describe the interfaces and links between functionally distinct parts of the system, such as how data relating to a vital event ‘moves’ through the system and its design limitations. Four business process maps were developed to review focused on the birth registration process for community and hospital births and the death registration workflow for home and hospital deaths. Development of the business process maps required intense engagement with key

• stakeholders. Several workshops were held to refine the maps with a number of different

stakeholder groups involved in the births and deaths registration process in Myanmar including general administrators; auxiliary midwives; community health workers; traditional birth attendance; community informers, free funeral services associations, basic health staff, immigration staff, CSO staff and members of the community based organizations. Complementary to CRVS system Architecture analysis, a qualitative assessment was conducted in 3 townships. Focus Group Discussion and In-depth Interview were undertaken with participation of approximately 300 key CRVS stakeholders. The findings from this would deepen our understanding of the complexity of the CRVS structure, system and process and knowledge, attitudes and perceptions of key individuals involved in the CRVS system (7). A range of assessment tools and data were applied in this study. The triangulation analysis was carried out for comparison and checking of findings from different data sources and methodologies, then the findings were presented jointly to draw a more comprehensive picture (7).

Figure (2) – Business process map for the community death registration system in Myanmar which was drawn by using bizagi software

Ten Critical Mile Stones in CRVS system in Myanmar Applying the principles of EA analysis, a strong CRVS system is important to have ten critical mile stones. Six critical mile stones are fall under the civil registration of the vital events (VE): notification, data validation, registration, certification, sharing of information and storage archiving of the VE. The remaining four fall under vital statistics and include compilation; quality control; generation and dissemination of vital statistics.

In Myanmar, six critical CRVS miles stones are currently functioning that are registration; certification; storage and archiving of vital events, compilation, generation and dissemination of the vital statistics. Four critical miles stones were missing or weak in the system including notification; validation, data sharing and proper quality assurance system. Those mile stones were present in sequence and they depended on each other. CRVS Milestones present in the Myanmar Registration VE: Community birth and death registration is mainly the responsibility

• f basic health staff (i.e. midwives and public health supervisor grade II) and township

medical officers through Rural Health Centers (RHC) and Township Medical Office (TMO). For the registration of hospital births and deaths are conducting by doctors from the hospitals. According to the annual statistical year book produced by the CSO, the completeness

• f birth registration (81%) in Myanmar was greater than deaths (57%) in 2014. The basic

health staff registered the VE as part of their routine tasks and rarely provided awareness on death registration to the community and the registration system is found as a passive registration system. Performance of the Myanmar CRVS system is however adversely affected by a lack

• f enforcement of the 2012 law requiring families to report birth and death cases to the local

General Administrative Department (GAD) within 3 days of occurrence and the GAD to report to the TMO. There is also poor awareness in the community of birth and death registration and the value of the birth and death certificates. Midwives have substantial workloads because of one midwife is being in charge of average 4 or 5 villages to provide primary health care services and could not register for all events by timely manner. The collaboration between the CRVS stakeholders at community level is also weak and there is no proper system to notify about the vital events from community to registered staff. Those are contributed to low completeness of the birth and death registration rate. The knowledge of community and stakeholders on importance of birth registration and certificates were higher compared to deaths. The importance of the birth registration is clear that the mother and children can obtain primary health care services including immunization services after the registration. The birth certificates are essential for school going children and a requirement when applying for a National Registration Card (NRC).

On the other hand, the people are lack of awareness on importance of death registration and certificates. Death certificate were rarely required and lack of incentive for death registration. One example was in the case of deaths of government staff for pension transfer and life insurance claims. Burial permission was not required in most of areas especially in rural areas. Therefore, the coverage of death registration was considerably low. In term of the registration forms, several information are required to record in the form including basic demography information of the participants, information related to social relationship and vital event. Due to the over workloads of midwives, they could not fill birth and death forms completely for all events, leading to lose the relevant epidemiological information including COD and reduce the efficiency of the registration process. Approximately 16% of total deaths were found as hospital deaths and the Causes Of Death are medically certified by the doctors. Majority of deaths (84% of total deaths) were community deaths and the reliable COD information are not available. The registration forms included to collect only discrete number for age of deceased or mothers instead of recording date of birth. Despite of that there were errors in age reporting due to age heaping Certification VE: Principally, there is no fee to request birth and death certificates. Birth and death certificates and burial certificates are responsible to issues by Township Medical Officers. The notification, registration and certification are depended each other. Due to the above mentioned reasons in the registration, the percentage completeness of birth certificates was greater than deaths. While the births certificates obtained for approximately

• ver 70% of under five years old children, there was only under 5% deaths were requested

for death and burial certificates. In term of the COD certificate, majority of deaths (84%) in Myanmar was found as community or home deaths and a standard medical certification of COD procedure was not present for the community deaths and importance mortality information was missing including causes of home deaths. Although hospital deaths (16%) were certified COD by doctors, critical errors was also found in the COD certificate. At least one error was found in 96% of 600 COD certificates and two errors were discovered in 72% of COD certificates. Storing and Archiving VE: The vital registration in Myanmar is currently paper based, as a result it can be costly to send and store the registration forms and books and they are at higher risk of deterioration. Despite that Myanmar is trying to transform its system to an electronically based data entry, storing and archiving system via the new Electronic platform (E platform).

Compilation, generation of data and dissemination of the reports: These three mile stones were related to Vital Statistics (VS) and mainly depended on the performance of the CSO. Most of the CSO staff are statisticians and the organization is well structured in data entry, compiling and analysis process. As the higher rate of staff transferred, the trained ICD coders were shortage and the reports for 2014 and 2015 was delay to produce. The vital statistics data is compiled using Microsoft Access software and ICD10 4 digits coding is used for cause of deaths. The vital statistic reports are usually published

• annually. The report describes disaggregated data such as sex, geographical areas, age groups

and causes of death. The estimation was also done for birth and death data. Before publishing the reports, the IAWG meeting validates the data among MOHS, CSO, GAD and the Department of Population and Immigration. The capacities of analytical in the estimate completeness of the registration and report presentation were essential areas to enhance for improving data accuracy and timeliness of the reports. In addition, there is no proper system or standard operation procedure to control the data quality, estimation completeness and data generation process. CRVS Milestones missing in the Myanmar System Notification VE: A proactive notification system of the vital events (VE) does not currently exist in the CRVS system contributing to be a passive registration system and difficulties in attaining 100% registration of VE in a timely manner. The collaboration between CRVS stakeholders at community level needs to be strengthen enable to establish a community-led notification system and raising the awareness of the community about the vital registration and certification. Data Validation and Sharing VE: The Coordination Committee on Births and Deaths Registration (CCBDR) was established including members from various levels but there was still a need to collaboration among key agencies in obtaining 100% registration of

• VE. Data discrepancy, incompleteness and inaccuracies were found after comparing the VE

from different data sources because there was missing the proper system for individual data sharing and data validation among key government agencies. Quality assurance: It is found that there were inaccuracy and incomplete information in the reporting including age heaping and errors in COD certificates at registration and certification steps. A quality assurance system has become essential to establish in the CRVS system and Standard Operation Procedure (SOP) is required for the data analysis process. The CSO staff are in need of strengthening capacities to establish and perform a standard

quality assurance system and to audit the VS using innovative and effective ways by regular basic. Ways forward: Strategic Innovative CRVS Improvement Activities CRVS Systems architecture and analysis was carried out as an innovative way to evaluate the CRVS system(6). Four critical steps do not currently exist in the system including: lack of proactive notification of births and deaths; data validation; sharing of individual records with key government agencies; and quality assurance. The other six milestones, although present, are in need of strengthening due to the low coverage of death registration, poor quality of COD data, age heaping and critical errors in COD medical certification practices. In the collaboration of the Government of Myanmar, the D4H Initiative is implementing a set of targeted interventions aimed at strengthening the functioned of the CRVS system by applying innovative technologies. Strategies for an appropriate notification system, increase community awareness and a systematic data validation and sharing system are implementing through the collaboration of key stakeholders. The registration forms are reviewed and revised according to the international standard to improve the quality of data and efficiency of data collection process. As an innovative technology, verbal autopsy is used to capture information on causes

• f community deaths, to improve the completeness of community death registration and to

reduce the burdens of data collection and entry staff by using tables in collecting information. The VA curriculum will be embedded into the courses of basic health staff, doctors and public health students for sustainable of the intervention. On the other hand, doctors are promoted their skills and knowledge on medical certification of COD process and assessment tools on the quality of COD certificates enable to improve the quality of COD and mortality data of health facility deaths. The mortality TWGs are formed at different level to review the quality of COD data and certificates in regular basic. The curriculums related to improve the COD would be developed and embedded in the courses of medical students and public health student in sustainable manner (6). Myanmar is also working with technical experts to improve capacities for ICD coding and analytical capacities for the calculation of completeness of the registration. For the quality assurance, the Mortality level and Causes of Deaths data assessment tool (ANACoDA) is applying as one of the innovative mortality assessment tool and it is useful

for auditing the VS and checking the registered records sequentially (6). Addition to that advocacy to decision makers and key stakeholders is conducting strategically for the integration of innovative activities into the existing CRVS system and changes in policy related to them. References 1. Department of Public Health. CRVS System Review Report. Nay Pyi Daw: Ministry

• f Health; 2014.

2. The Central Statistical Organization. Sample Survey on Evaluation of the Completeness of Vital Registration System in Myanmar Nay Pyi Taw; 1995. 3. Soe Myint, Aye Moe Moe Lwin. Study on Completeness of Mortality Statistics in

• Myanmar. Nay Pyi Daw: Department of Healht Planning; 2014.

4. Philip W S, Lene M, David E P, Carla A, Don de S, Rafael L, et al. A global assessment of civil registration and vital statistics systems: monitoring data quality and progress. www.thelancet.com 2015;386:1395-1406. 5. John O. Action Evaluation of Health Programmes and Changes : A handbook for a user-focused approach. 2007:113. 6. Bloomberg Data For Health Initiative. Innovation Profile of Bloomberg D4H(https://innovationxchange.dfat.gov.au/sites/dfat/files/D4H%20Innovations_0.pd f). In; 2016. 7. Ellie Fossey, Carol Harvey, Fiona McDermott, Davidson. L. Understanding and evaluating qualitative research. Australian and New Zealand Journal of Psychiatry 2002;36(6):717-732. Lead Author: Khin Sandar Bo (MPH), CRVS Country Coordinator Bloomberg Data for Health Initiative the Vital Strategies, Office no. (32), Zeyar Htani Road, Nay Pyi Taw, Myanmar sbo@dataforhealth.org Co-Authors: Alan D Lopez (PhD), Laureate Professor the University of Melbourne Director, Bloomberg Initiative for CRVS Melbourne School of Population and Global Health Building 379, 207 Bouveries St, Carlton 3053 VIC, Australia: alan.lopez@unimelb.edu.au : Joan Sarah Thomas (MPH), Senior Program Officer Vital Strategies | Building Health Systems Globally, An affiliate of The Union 146 Robinson Road, #06-01, Singapore 068909, Singapore JThomas@vitalstrategies.org