The World Health Organization (WHO)’s estimate of excess deaths due to COVID-19 in India triggered several responses. Among them was the response of several State Health Ministers, who slammed the WHO and asserted that India has a “robust, legal and transparent system for data collection and COVID mortality surveillance”.
This new-found love for the Civil Registration System (CRS), which was rarely being used as a source of vital statistics, is surprising. The claim was not even made by the Office of the Registrar General of India (ORGI), which is well aware of the drawbacks of the system, but by politicians. As such, I thought it necessary to place in the public domain some of the facts relating to the quality and completeness of birth and death registrations in the country.
Actual levels of registration
The registration of births and deaths is governed by the Registration of Births and Deaths (RBD) Act, 1969. While the State governments are responsible for the establishment and management of the registration system, the Registrar General of India (RGI), who is appointed by the Central government, coordinates and unifies the activities of registration.
Based on a comparison with the vital rates obtained from the sample survey called the Sample Registration System (SRS), the RGI estimated that the country registered about 92.7% of births and 87.8% of deaths in 2019. Corresponding figures for 2020 are not available. Past studies on the SRS indicate that the vital rates are underestimated by 2-3%. This would mean that the levels of registration are probably closer to 90% for births and 85% for deaths.
The number of births and deaths registered in a year include those of earlier years. Some births and deaths are registered only in the following year. This is so even in normal circumstances. For instance, a birth/death in December can be registered in January as 21 days are available for reporting events for registration.
Events reported after 21 days can be registered under the RBD Act. Data provided in the 2020 annual report show that the number of births and deaths registered one year after occurrence is quite high. For example, in Bihar, of the 30.4 lakh births registered in 2020, nearly 7.2 lakh had occurred in 2019 or earlier. In Uttar Pradesh, of the 48.5 lakh births registered in 2020, 5.8 lakh had occurred earlier. More than 15% of the births registered had occurred in earlier years in Uttarakhand, Jharkhand, Rajasthan and Assam. In Nagaland, the figure was as high as 90%.
In the case of deaths, the proportion of delayed registration was lower. Among the larger States, more than 10% of the deaths registered in 2020 had occurred in earlier years in Assam (13.3%), Jharkhand (14.7%), Rajasthan (15.3%), Uttarakhand (14.8%) and Uttar Pradesh (13%).
To register a birth or death reported after a year of its occurrence requires an order of a First Class Magistrate issued after verifying the facts about the birth or death. In several States, this function has been given to the Sub-Divisional Magistrates. In 2020, about 20.5 lakh births and 7.6 lakh deaths that had occurred over a year earlier were registered. This does not include data for Maharashtra, Delhi, and Sikkim. In 2019, the corresponding figures were 21.6 lakh births and 5.3 lakh deaths. Assuming about 250 working days in a year, on average more than 11,000 delayed registrations are ordered by the Magistrates every day. I am not convinced that these orders are issued after verifying the facts, as required by the law. It may also be noted that this number did not change much in 2020 despite lockdowns.
A robust system should be able to ensure the registration of almost every birth and death within a short time after its occurrence. If we remove from the 2020 data, or the data for any year, the events registered with substantial delay, say three months or more, the picture of completeness would be very different.
COVID-19 impact on registration
COVID-19 resulted in prolonged lockdowns. These could have significantly affected the efficiency of the CRS in the following manner. One, the registrars could not work during lockdowns in many areas. Two, people could not travel to the registrar’s office to report the births/deaths that had occurred at home within the prescribed time. Three, in case of a delay of more than 30 days in reporting, the procedure of getting an affidavit or a Magistrate’s order as required under Section 13 of the RBD Act is cumbersome. Since it is a requirement under the Act, it could not be relaxed through executive orders. Four, in some States, the functionaries handling registration were deployed on COVID-19-related duties and could not register the events.
The impact of these would not have been uniform across the country as some areas had longer periods of lockdowns or travel restrictions.
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One can reasonably expect that a large number of births and deaths that had occurred in 2020 would have been reported for registration in 2021 or even later. It is likely that a reasonable number of deaths, especially among women and children, may not get registered at all because the family may not require the death certificates for settling inheritance, insurance claims, etc. Female deaths formed only 39.8% of the total registered deaths in 2020. This was slightly lower than the corresponding figure of 40.4% recorded in 2019. The percentage of female deaths registered was lowest in Nagaland (26.7%) and highest in Kerala (44.9%). The fact that these numbers are so low points to the need for improvements in the registration system. It is also well known that child deaths have very low levels of registration. This can easily be seen by comparing the registered infant/child deaths with an estimate based on the rates from the SRS. COVID-19 may have worsened the situation to some extent, but it also acted as an eye-opener on the importance of the CRS.
Only about 20% of the deaths have a Medically Certified Cause of Death (MCCD) that conforms to the WHO standard. In other cases, the cause of death is provided by the attending medical practitioner in case of deaths in medical facilities and by the person reporting the death in domiciliary deaths. The State governments have not issued statutory notifications to increase the coverage of MCCD.
Not a strong defence
Thus, the CRS has several shortcomings. These facts do not support the argument that India has a robust system of registering births and deaths. The CRS is yet to mature into a robust and resilient system that can ensure that every birth and death is registered even in normal times, let alone during a pandemic.
While the law and a registration system are in place, it is necessary that the State governments put in more effort to ensure that all births and deaths are registered and more deaths have medically certified causes. This would require coordinated action by several departments of the State that have a stake in the CRS. It is also necessary to publish data in a timely manner so that so that it can aid the formulation of policies and programs backed by evidence.
K. Narayanan Unni is former Deputy Registrar General, CRS, and a retired Indian Statistical Service officer. Email: firstname.lastname@example.org