In May 2016, the Health Secretaries of the States and Union Territories of India gathered in the capital and issued “The Delhi Commitment on Sustainable Development Goals for Health”. Among others, the document acknowledged the need to invest in health data collection, analysis and research so that these can properly inform government policies and strategies necessary to address the various challenges facing India’s healthcare. Such commitment is imperative, given that the success of global SDGs over the next 15 years will largely depend on India’s performance. Measuring progress closely to ensure mid-course corrections when needed should be key to India’s health strategy. To examine the issues related to insufficient, district-level data for customised and evidence-based planning, the Observer Research Foundation organised a panel discussion in July 2016, bringing together experts in the field. This paper builds on the key themes discussed by the panel, and from these, draws policy lessons for the road ahead.
About the author
Oommen C Kurian is Fellow, Public Health, at the Observer Research Foundation. He is a researcher trained in economics and community health at the Jawaharlal Nehru University, New Delhi. His research interests include health policy issues, among them, the use of large datasets to analyse health trends and explore workable solutions to the issues confronting the sector. He has previously worked with Oxfam India, Action Aid India, Centre for Enquiry into Health and Allied Themes (CEHAT), Office of the Commissioners of the Supreme Court (Right to Food Case), Centre for Women’s Development Studies (CWDS), Centre for Social Medicine & Community Health (CSMCH), JNU, and Women’s Studies Programme, JNU. He wishes to acknowledge two anonymous referees for their valuable inputs on an early draft of this paper.
“The time spent by the field worker, especially auxiliary nurse midwives, on maintaining various registers and records ranges from 20-30 percent of the total working time. This naturally cuts down the time available for field work.” – 1979, India[1]
Introduction
Health information gathering is a key component of any working health system. However, this function is weak in low and lower middle-income countries, which are perennially plagued by problems of having data that are not only poor in quality but also inadequate for properly informing health policy.[2] Data capture is often seen as an additional burden on the already scarce human resources, which further weakens implementation capacity.
In the case of India, this systemic weakness has long been identified and acknowledged by the government. The National Health Policy of 2002 recognised the dire need for systematic and scientific population health statistics.[3] Initial assessments have identified several key issues such as lack of information on non-communicable diseases and injuries, dearth of primary data on causes of death, lack of private health sector numbers, and insufficient data at the district level.[4] India’s achievements with health data remain limited, considering that it has been a pioneer among developing countries in establishing data systems: the National Sample Surveys (NSS) was initiated in 1950, and the Sample Registration System, in the 1960s.[5]
In such a fragmented landscape, government ministries are often left with no choice but to depend on different and incompatible datasets. For example, key central ministries disagreed on whether India was on-track in achieving crucial targets of the Millennium Development Goals (MDG). A case in point is MDG 5, whose target was reduction of maternal mortality ratio (MMR) by three-quarters between 1990 and 2015. While the numbers published by the health ministry (MoHFW)[6] indicated that India will achieve this goal, the Ministry of Statistics (MoSPI) was less optimistic.[7] It turned out, however, that their respective estimations were based on two separate sets of numbers.
In early 2016, around 200 countries agreed in principle on a global indicator framework as a starting point for the 2030 Agenda and the SDGs. The 17 goals and 169 targets of the SDG framework are complemented by 230 indicators, which is a five-fold jump from the MDGs’ 48 indicators. The MoSPI and NITI Aayog are in the process of integrating the SDGs into national planning processes and finalising the national indicator framework.[8]
Nevertheless, MoSPI suggests that India currently has the capacity to produce data for only 23 out of the 230 SDG indicators. According to officials, with additional investments, India can perhaps produce data for systematically tracking some 50-60 indicators. [9] For the same reason, it will be a huge challenge to identify measurable indicators for tracking national health goals aligned to the SDG goals.[10] NITI Aayog had set itself a deadline of end-2016 for finalising a set of indicators to monitor progress across national development goals.
It is widely accepted that the MDG framework of vertical goals has contributed to the current fragmented approaches to development.[11] The SDG framework tried to overcome this anomaly by introducing a broader set of goals. Tracking these goals is going to be a daunting challenge for governments, international agencies, as well as national statistical offices. To understand the huge regional, inter- and intra-state disparities better in order to remedy them, large amounts of new information will be required. Indeed, a ‘data revolution’ is needed in terms of making disaggregated data publicly available if India is aiming to achieve—or get anywhere near—the ambitious SDG targets related to health, including those on nutrition.[12] The following sections offer four recommendations to streamline and build on the existing national statistical infrastructure to facilitate such a data revolution.
Recommendation 1: Transform Civil Registration and Vital Statistics (CRVS) systems to achieve universal coverage.
A Civil Registration System (CRS) can be considered complete if it covers at least 90 percent of all live births and deaths taking place within a country or area.[13] India has made considerable improvement over the last decade in terms of its Civil Registration and Vital Statistics (CRVS) systems coverage (See Table 1). The National Population Policy 2000 had set the goal of achieving universal birth registration by the year 2010. However, the coverage is not yet enough where the data at the national level can be used to inform decision making. Still, as of 2013, there are 28 States/UTs where the coverage of birth registration is more than 90 percent, and 17 States/UTs where the coverage of death registration is more than 90 percent.[14]
Box 1: The significance of CRVS systems for the health system
Unlike other sources of vital statistics such as censuses and household surveys, the data from Civil Registration and Vital Statistics (CRVS) systems permit the production of statistics on population dynamics, health, and inequities in service delivery on a continuous basis for the country as a whole and for local administrative subdivisions. This provides more accurate information and the ‘denominator’ for assessing progress with plans across sectors for improving economic growth and reducing poverty. Accurate vital statistics and the ability to monitor and respond to causes of death and disability underpin many global targets, including new commitments to universal health coverage and tackling the global epidemic of non-communicable diseases.
Information on the cause of death, when disseminated through vital statistics, can (i) improve the allocation of resources in health services; (ii) provide early insights into trends in disease prevalence so that health officials can design prevention or intervention strategies; (iii) provide more accurate estimates of maternal mortality than are available from other sources; and (iv) reveal unusual patterns of deaths by cause that point to the need for timely interventions.
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Source: http://www.who.int/healthinfo/civil_registration/WB-WHO_ScalingUp_InvestmentPlan_2015_2024.pdf & http://data2x.org/wp-content/uploads/2014/08/CRVS-Asia-and-Pacific_Knowles.pdf
The overall level of birth registration in India was 85.5 percent in 2013, and according to official sources, 17 States/UTs have achieved the target of 100-percent birth registration, as of 2013. However, there are sharp inter-state differences, and if the two most populous and poorest performing States (Bihar and Uttar Pradesh) are excluded from the analysis, the level of registration of births rises to 96.8 percent. Similarly, the level of registration of deaths was at 70.9 percent in 2013; and as of 2013, 11 States/UTs have achieved the target of 100-percent registration of deaths. Repeating the exercise and excluding Bihar and UP from the analysis, the level of registration of deaths reaches 85.2 percent. Overall, only eight States/UTs have achieved the target of 90-percent in both birth and death registrations, as of 2013.[15]
Table 1: Civil Registration and Vital Statistics (CRVS) systems coverage in India
| Children under 5 years whose birth was registered (%) | Level of Registration of Births | ||||
| State | NFHS 4 2015-16 | NFHS 3 2005-06 | CRS 2013 | ||
| Urban | Rural | Total | Total | Total | |
| West Bengal | 97.3 | 96.7 | 96.9 | 75.8 | 92.8 |
| Uttarakhand | 81.8 | 74.2 | 76.7 | 38.4 | 76.6 |
| Tripura | 96.8 | 89.9 | 91.6 | 74.4 | 91.4 |
| Telengana | 89.9 | 76.5 | 82.9 | NA | 100 |
| Tamil Nadu | 98.5 | 98.2 | 98.3 | 85.8 | 100 |
| Sikkim | 98.6 | 98.4 | 98.5 | 85.7 | 79.9 |
| Puducherry | 99.2 | 98.7 | 99 | NA | 100 |
| Meghalaya | 89.2 | 78.4 | 79.8 | 43.3 | 100 |
| Manipur | 74.8 | 59.7 | 64.8 | 30.4 | 100 |
| Maharashtra | 95.8 | 94.6 | 95.1 | 80 | 100 |
| Madhya Pradesh | 92.2 | 78.4 | 81.9 | 29.7 | 84.1 |
| Karnataka | 95 | 94.9 | 94.9 | 58.3 | 96 |
| Haryana | 94 | 94.3 | 94.2 | 71.7 | 100 |
| Goa | 98.9 | 99 | 98.9 | 94.7 | 100 |
| Bihar | 64.5 | 60.3 | 60.7 | 5.8 | 57.4 |
| Assam | 97.4 | 93.8 | 94.2 | 43 | 97.7 |
| Andhra Pradesh | 90.1 | 79.9 | 82.7 | NA | 98.5 |
| A & N Islands | 97.2 | 98.4 | 97.9 | NA | 95.8 |
Source: NFHS-4 state factsheets, CRS 2013 Report
According to the latest available CRS data (2013), the share of rural areas in total infant deaths registered is only 33.1 percent. While this may suggest under-reporting in the rural areas, it could also be because deaths are registered at the place of death rather than residence. The share of overall male birth registration is 53 percent and female birth registration is 47 percent. Similarly, male deaths registered is 58 percent of total and female deaths, 42 percent, showing considerable difference.[16] State-wise figures on sex-disaggregated proportions of registered births and deaths are given in Table 2.
Table 2: Sex-wise Registered Births and Deaths of Major States (in’000), 2013
Experts emphasise that further research is needed to determine the extent to which such gender-based differentials in registration numbers represent a relatively low probability of registration for women and/or true sex differences in fertility or mortality levels themselves.[17] While previous NFHS rounds have reiterated rural-urban differences in birth registration, gender-based differences are not seen across the country, barring some states. [18] An assessment of the quality of CRS data conducted in 2014 found that Rajasthan under-registered female births. [19] Inequities based on income also remains a major constraint in achieving birth registration coverage, as Graph 1 clearly shows.
Graph 1: Birth registration of children under 5 years, by wealth quintile
In 2014, India announced a ‘Vision 2020’ plan towards achieving universal registration of births and deaths by 2020. However, given the trends in the low-performing states, this goal appears unlikely to be achieved with the current efforts. The key strategies include dissemination of a physician’s manual for improving cause-of-death reporting. In addition, a standardised web-based software application has been developed in order to avoid different packages being used across states. [20] Another transformational initiative is the National Population Register (NPR), an electronic database of more than 1 billion residents of the country. The process of removing duplicates from the database and assigning unique identity numbers is underway. An initiative has also been launched to integrate the population register with the civil registration system. [21]
CRS has been in operation in India for a long time, and carries the legacies of the colonial rule. The diversity within the system often comes in the way of cross-coordination. A study by the United Nations Population Fund (UNFPA) in 2013 showed that as administrative systems differed considerably across India prior to independence, the timing of its introduction and the modality has also varied across space. Despite some uniformity after the introduction of the Registration of Births and Deaths Act in 1969, the actual registration is done by officials in the state governments from diverse departments. [22] Most of these officials have different primary roles, and registration of births and deaths often receives a low priority. It is observed that although interdepartmental committees exist at the state level, they are often ineffectual, adversely affecting the completeness and quality of the CRVS system. [23]
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