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 of 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 of 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 obligates families to report births and deaths within 3 days (3). During 20 th 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
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