Counting on Each Other: How can we fight the spread of COVID-19 when half of deaths worldwide go unrecorded?

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This article is part of a series in which OECD experts and thought leaders — from around the world and all parts of society — address the COVID-19 crisis, discussing and developing solutions now and for the future. It aims to foster the fruitful exchange of expertise and perspectives across fields to help us rise to this critical challenge. Opinions expressed do not necessarily represent the views of the OECD.

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Co-authored by Dominique Charron, Vice-President, Programs and Partnerships, International Development Research Centre, Canada

Dominique Charron is IDRC’s Vice-President, Programs and Partnerships. Prior to being Vice-President, Dominique was the Director of IDRC’s Agriculture and Environment program area. She supervised research focused on increasing agricultural productivity and food security, reducing vulnerability to climate change, and protecting the public against infectious diseases and non-communicable diseases. Dominique joined the Centre in 2006 as head of the Ecosystems and Human Health program. Previously, she managed research programs at the Public Health Agency of Canada. Dominique Charron holds a PhD in epidemiology and a Doctor of Veterinary Medicine from the University of Guelph.


Data systems in many countries are not adequately equipped to deliver crucial data for fighting COVID-19. Registration of deaths with causes – a key indicator for tracking and understanding the pandemic – is comprehensive in fewer than 20% of the countries in sub-Saharan Africa, according to the United Nations.

The COVID-19 pandemic of a new and highly contagious viral disease has also triggered the worst global economic crisis since the Great Depression. To effectively respond to COVID-19 and the subsequent economic fallout, governments around the world need the right data at the right time – complete, reliable and timely data on everything from infection and mortality rates to knowledge about co-morbidities in the population. In a recent publication, the International Development Research Centre finds that in times of crisis, Civil Registration and Vital Statistics (CRVS) systems with universal (or nearly universal) coverage are a vehicle for governments to deliver effectively on social protection policies to vulnerable groups, the majority of whom are women and children. And yet, there are critical gaps in current data systems in low- and middle-income countries as outlined in a recent policy paper by the OECD’s Development Co-operation Directorate, Key trends in development co-operation for national data and statistical systems.

More on the Forum Network: Calling BS: Data reasoning during an infodemic by Jevin West & Carl Bergstrom, authors of Calling Bullshit: The Art of Scepticism in a Data-Driven World

Vital gaps

When British physician John Snow traced the source of an outbreak of cholera in London in 1854 to a water pump that victims had used, his finding prompted simple actions that helped stem the outbreak and launch the field of epidemiology. Snow’s breakthrough discovery was made possible because he had vital information on each victim thanks largely to the fact that local authorities in every English parish, by law, maintained registers of births and deaths from as early as the 1830s work proved foundational in demonstrating the need to establish and maintain records of vital events. As a component of well-functioning CRVS systems, the accurate registration of cause of death can help policy makers understand the impact of health crises and consequently deliver the most effective policy responses.

Today, more than 180 years since Snow’s breakthrough on cholera, a significant number of countries still do not accurately record vital events through civil registration. While the full extent of this lack of coverage is not known, estimates suggest that worldwide about half of all deaths and their causes go unregistered, and unrecorded deaths tend especially to be those of women. In fact, not a single low-income country was judged to have a complete registry of vital events in 2019. Moreover, the speed of progress towards wider coverage has been glacial, increasing by only 2.4 percentage points between 1980 and 2009, according to Mikkelsen et al

Estimates suggest that worldwide about half of all deaths and their causes go unregistered, and unrecorded deaths tend especially to be those of women.

The failure to routinely produce data on deaths with causes severely affects our understanding of the impact of COVID-19 in the developing world. Low- and middle-income countries account for nearly 85% of the world’s population, but only 62% of confirmed cases and 58% of recorded COVID-19 deaths, according to John Hopkins University data in mid-October 2020. While there are several potential explanations for these differences – demographics, in particular – data gaps likely play a role.

Consider first indicators on excess deaths: the number of deaths from all causes during a crisis above and beyond what one would have expected to see in normal years. Excess deaths have been a guide to understanding the impact of COVID-19, especially during the early months of the pandemic when testing was in short supply. In Ecuador, for instance, a country which according to the WHO registered more than 80% of all deaths in 2016, excess deaths reportedly overtook those officially attributed to COVID-19 by a factor of 15 early in the pandemic. This suggests the pandemic had a significantly larger mortality impact at the time.

Yet excess deaths can only be calculated if a sufficiently large fraction of deaths are registered in the first place. OECD analysis undertaken for this article indicates that countries that routinely registered fewer deaths pre-pandemic are also reporting far fewer COVID-related deaths – on average, only 50% of the cases reported in countries that register at least 90% of all deaths (Figure 1). As low- and middle-income countries often have weaker vital registration systems, not only are excess deaths much harder to calculate but the full extent of mortality from COVID-19 may never be accurately known. These data gaps limit design of the right policy responses. Data are key to building well-functioning health systems and effectively targeting resources so that populations live longer, healthier lives.

Figure 1: Countries with weaker death registration systems also consistently report fewer deaths from COVID-19

Note: This figure is based on a sample of 107 countries (15 lower middle-income, 37 upper middle-income and 55 high-income), of which 71 registered cause of death for at least 90% of all deaths; 90% confidence intervals are indicated. Low-income countries are excluded from the analysis due to a lack of data on completeness of death registration coverage. 

Source: OECD staff calculations based on COVID-19 death rates from John Hopkins University (extracted 16 October 2020), completeness of death registration coverage (2019 or the most recent observation) from the World Bank’s World Development Indicators and the World Bank’s country income classifications.  

Counting on co-operation

The benefits of well-functioning CRVS systems extend far beyond having accurate and timely population statistics. Birth registration, a fundamental human right enshrined in the Convention on the Rights of the Child, is often instrumental for the exercise of other rights such as participation in the political process and accessing education, health care, social protection and other public services. There is empirical evidence that birth registration can increase educational attainment and complements other measures such as legislation banning child labour.

Building reliable and complete CRVS systems is not easy and will take time. The experience from countries that have modernised their civil registration systems shows that it takes strong political will, leadership at the highest levels of government, clear objectives, adequate financing and the vision and capacity to conduct long-term planning. Incentives must be put in place to promote the accurate registration of vital events in the population and to foster cross-sectoral co-operation between ministries and agencies that are in charge of different programmes at national and subnational levels. Social protection systems can provide important incentives to register life events.

In the past, providers of development co-operation have favoured supporting household surveys, but the considerable time lag between data collection and the publication of results is not practical in terms of understanding causes of deaths during pandemics. As made clear by the problems that the lack of data and weak data systems pose for the fight against COVID-19, international development actors must do more to help developing countries expand and improve CRVS systems that will also be resilient in emergency situations. 

There are encouraging signs that progress is possible

The Sustainable Development Goals (SDGs) are providing a boost to the CRVS agenda. The global goals include separate targets for provision of legal identity for all, including birth registration (SDG 16.9) and for support to statistical capacity, monitored by tracking the proportion of countries that have achieved 100% birth registration and 80% death registration (SDG 17.19).

Furthermore, CRVS systems can contribute to achieving the SDGs. They can provide the high level of disaggregation in development data that the global goals called for. Indeed, one study for the World Bank Group finds that CRVS systems with sufficient coverage can be used to monitor at least 67 SDG indicators. In the long run, everyone stands to benefit from better CRVS coverage in key sectors – including social protection, population health and access to education – because it improves the evidence base for policy making and results. 

Read the OECD Policy Response on our COVID-19 Hub: Supporting Livelihoods During the COVID-19 Crisis: Closing the gaps in safety nets

In their international development policies, OECD countries are increasingly showing they are willing to tackle the challenge of supporting CRVS systems in line with their UN pledge to leave no one behind. Several OECD Development Assistance Committee members – including Australia, Canada, France, Sweden, Switzerland and the United Kingdom – are supporting international initiatives to ensure legal identity for all, which often focus on birth registration. The Australian government works with the Bloomberg Philanthropies Data for Health Initiative across 20 countries in Africa, Asia, the Pacific and Latin America. The initiative develops country-level capacity to collect better public health data, with an emphasis on innovative methods that will improve CRVS data collection and the use of data to drive decision making. (Learn more in the OECD Data for Development case studies).

The Canadian government places a high priority on support for CRVS systems in Asia and Africa, with a CAD 100 million investment in the Global Financing Facility earmarked for CRVS systems strengthening. Canada and the IDRC also founded the Centre of Excellence for CRVS Systems, a unique global hub that supports and advocates for stronger CRVS systems worldwide. 

The coronavirus crisis, just like the United Kingdom’s cholera outbreak a century and a half ago, underscores that timely registration of all vital events – births, marriages and especially deaths with their causes – can underpin effective policy making and responses that will help fight pandemics and save lives. We must now use the fight against COVID-19 to accelerate action more broadly to help countries meet their goals to have comprehensive CRVS systems. With adoption of the 2030 Agenda for Sustainable Development in 2015, the international community agreed on SDG 16: Peace Justice and Strong Institutions. Every country should have universal, continuous and complete registration of its population’s vital events, throughout the life cycle and regardless of race, sex, religion or ethnic group.

20 October is World Statistics Day. This year, on the same date, the international community is coming together for the 3rd United Nations World Data Forum. Let us add a silver lining to this pandemic by rallying the dedicated leadership and sufficient resources required to make complete registration of vital events a reality. The international community must play its part by providing predictable, co-ordinated and greater financial and technical support for CRVS systems in low- and middle-income countries. By achieving complete civil registration by 2030, we will contribute to ensuring that every person is counted – and counts. Policy makers and health systems, armed with reliable data about the risks and causes of death, make for healthier, safer and longer lives for all.

References
[1] AbouZahr, C. and T. Boerma (2005), “Health information systems: The foundations of public health”, Bulletin of the World Health Organization, Vol. 83/8, pp. 578-583, https://www.who.int/bulletin/volumes/83/8/578.pdf?ua=1
[2] Centre of Excellence for Civil Registration and Vital Statistics (CRVS) Systems (2020), The Nexus Between Civil Registration and Social Protection Systems: Five Country Practices, International Development Research Centre, Ottawa, ON, Canada, https://crvssystems.ca/sites/default/files/assets/files/SocialProtection_Compendium_e_WEB.pdf
[3] Corbach, A., S. Brito and R. Osorio Rivas (2012), “Birth Registration and the Impact on Educational Attainment”, IDB Working Paper Series No. IDB-WP-345, https://publications.iadb.org/publications/english/document/Birth-Registration-and-the-Impact-on-Educational-Attainment.pdf
[4] Fagernäs, S. (2014), “Papers, Please! The Effect of Birth Registration on Child Labor and Education in Early 20th Century USA”, Explorations in Economic History, Vol. 52, pp. 63-92, https://doi.org/10.1016/j.eeh.2013.09.002
[5] Lange, S. (2020), “Key trends in development co-operation for national data and statistical systems”, OECD Development Policy Papers, No. 31, OECD Publishing, Paris, https://doi.org/10.1787/1ce044d2-en., No. 31, OECD Publishing, Paris,https://doi.org/10.1787/1ce044d2-en
[6] León Cabrera, J. and A. Kurmanaev (2020), “Ecuador’s Death Toll During Outbreak Is Among the Worst in the World”, The New York Times, https://www.nytimes.com/2020/04/23/world/americas/ecuador-deaths-coronavirus.html (accessed on 20 October 2020)
[7] Mikkelsen, L. et al. (2015), “A global assessment of civil registration and vital statistics systems: Monitoring datauality and progress”, The Lancet, Vol. 386/10001, pp. 1395-1406, https://doi.org/10.1016/S0140-6736(15)60171-4
[8] Mills, S. et al. (2017), Civil Registration and Vital Statistics (CRVS) for Monitoring the Sustainable Development Goals (SDGs), World Bank Group, Washington, DC, http://documents.worldbank.org/curated/en/979321495190619598/Civil-registration-and-vital-statistics-CRVS-for-monitoring-the-Sustainable-development-goals-SDGS
[9] OECD (2017), “Case studies on data for development”, in Development Co-operation Report 2017: Data for Development, OECD Publishing, Paris, https://doi.org/10.1787/dcr-2017-46-en

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Jorge Moreira da Silva

Director of Development Co-operation, OECD

Mr. ‌ Moreira da Silva is since 1st November 2016 the Director of the Development Co-operation Directorate (DCD) at OECD. As Director of the Development Co-operation Directorate (DCD), Mr. Moreira da Silva plays a key role in positioning the OECD’s work on development co-operation at the leading edge. He supports the work of the Development Assistance Committee (DAC) and collaborates closely with other components of the OECD's Development Cluster to strengthen the Organisation’s contribution to the international governance architecture, as well as to OECD-wide initiatives such as NAEC, Inclusive Growth, and work in support of the Sustainable Development Goals (SDGs).

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