Strengthening civil registration and vital statistics systems in the Pacific: the Fiji experience

Transcription

1 Theme: Strengthening vital statistics and cause-of-death data Strengthening civil registration and vital statistics systems in the Pacific: the Fiji experience Shivnay Naidu Michael Buttsworth Audrey Aumua WORKING PAPER Strengthening health systems in Asia and the Pacific through better evidence and practice An AusAID funded initiative For the PDF version of this paper and other related documents, visit

2 About this series The s Working Paper Series is the principal means to disseminate the knowledge products developed by the hub as easily accessible resources that collectively form a lasting repository of the research findings and knowledge generated by the hub s activities. Working papers are intended to stimulate debate and promote the adoption of best practice for health information systems in the region. The series focuses on a range of knowledge gaps, including new tools, methods and approaches, and raises and debates fundamental issues around the orientation, purpose and functioning of health information systems. Generally, working papers contain more detailed information than a journal article, are written in lessacademic language, and are intended to inform health system dialogue in and between countries and a range of development partners. Many working papers have accompanying products such as summaries, key points and action guides. The full range of documents, as well as other resources and tools, is available on the Health Information Systems Knowledge Hub website at tools. This research has been funded by AusAID. The views represented are not necessarily those of AusAID or the Australian Government. Author details Shivnay Naidu, Fiji Ministry of Health Michael Buttsworth, University of Queensland Audrey Aumua, University of Queensland The University of Queensland 2013 Published by the Health Information Systems Knowledge Hub, School of Population Health The University of Queensland School of Population Health Building, Herston Rd, Herston Qld 4006, Australia Please contact us for additional copies of this publication, or send us feedback: hishub@sph.uq.edu.au Tel: Fax: Acknowledgments This document credits the achievements of the following key partners: Fiji Ministry of Health (MoH), Fiji Islands Bureau of Statistics (FiBOS), and Fiji Ministry of Justice and Public Enterprises and the Office of the Registrar General (RGO) Births, Deaths & Marriages. These partner agencies understand the benefits of an improved and more functional civil registration and vital statistics (CRVS) system in Fiji and realised the need for their agencies to work together to achieve this common goal. Without their willingness, devotion, determination, and tireless and concerted efforts to advancing the CRVS agenda in Fiji, none of the achievements outlined in this paper would have been possible. Particular recognition goes to Mr Serevi Baledrokadroka (FiBOS), who in partnership with the lead author of this paper, Mr Shivnay Naidu (MoH), was responsible for driving the agenda and chairing the CRVS committee meetings. Further praise and thanks goes to all members of the committee including: Mrs Merewalesi Raikoti (FiBOS), Mrs Lolohea Baro (RGO), Miss Marica Ravutu (RGO), Mrs Leba Drole (RGO), Mrs Ruci Vuadreu (MoH), Mrs Kelesita Mataitoga (MoH) and Mrs Talatoka Tamani (MoH). These individuals were a constant presence at committee meetings and took an active role in the numerous activities that have contributed to the committee s successes. Beyond the immediate committee members and critical to the progress and accomplishments witnessed, was the high-level commitment and support from stakeholder ministries, particularly the Minister of Health, Dr Neil Sharma, and Permanent Secretary of Health, Dr Eloni Tora. Appreciation is also extended to the Brisbane Accord Group partners for their technical support and assistance in this process. These partners include: the at the University of Queensland, the Secretariat of the Pacific Community, the United Nations Population Fund, the World Health Organization, the United Nations Children s Fund, the Pacific Health Information Network, the Australian Bureau of Statistics, Queensland University of Technology, the University of New South Wales and Fiji National University. This working paper documents the experiences and accomplishments to date of all those involved in the process of strengthening the CRVS system in Fiji. Design by Biotext, Canberra, Australia

3 Contents Acronyms and abbreviations... 4 Summary... 5 Introduction... 6 The strategic importance of civil registration and vital statistics... 7 Civil registration and vital statistics in Fiji... 9 Strengthening civil registration and vital statistics in Fiji...18 Conclusions Appendix A: Early history of civil registration and vital statistics strengthening in Fiji References

4 Acronyms and abbreviations ABS ACME AusAID BAG BDM CRVS DBA DOA ESCAP FiBOS FNPF FNU HIS HIS Hub HIU HMN ICD-10 ITC LBR MCCD MCD MDG MoH MoJ NBR NCD PATIS PHIN PIN QUT RGO SPC UN UNDP UNESCAP UNICEF UNFPA UNSW UQ WHO Australian Bureau of Statistics Automatic Classification of Medical Entry Australian Agency for International Development Brisbane Accord Group births, deaths and marriages civil registration and vital statistics dead before arrival dead on arrival United Nations Economic and Social Commission for Asia and the Pacific Fiji Bureau of Statistics Fiji National Provident Fund Fiji National University health information system Health Information Unit Health Metrics Network International Statistical Classification of Diseases and Related Health Problems, 10th revision Department of Information Technology and Computing Services late birth registration medical certification cause of death medical cause of death Millennium Development Goal Ministry of Health Ministry of Justice and Public Enterprises new birth registration non-communicable disease patient information system Pacific Health Information Network personal identification number Queensland University of Technology Office of the Registrar General / Registrar General s Office Secretariat of the Pacific Community United Nations United Nations Development Programme United Nations Economic and Social Commission for Asia and the Pacific United Nations Children s Fund United Nations Population Fund University of New South Wales University of Queensland World Health Organization 4

5 Summary In this paper, we describe Fiji s experience of strengthening its civil registration and vital statistics (CRVS) system and the processes it undertook to achieve this. By documenting this, we highlight key lessons that can inform other Pacific Island countries embarking on this journey. Key lessons learned 1. Ensure country ownership of the strengthening process of the CRVS system. 2. Identify a CRVS champion(s) to drive the process forward and maintain momentum. 3. Conduct a rapid assessment that is country-led and engages the right stakeholders. 4. Engage development partners to provide technical support and assistance with planning. 5. Engage stakeholders and establish a CRVS committee (collaborate, communicate and document processes; ensure strong leadership and senior management support). 6. Establish guidelines and processes for sharing data and knowledge between agencies and ensure this sharing occurs. 7. Identify country strengths and quick wins and build on these. 8. Strengthen technical elements of the CRVS system alongside broader systemic issues (e.g. staff training / capacity building, standardised processes). 9. Advocate and increase awareness of the importance of CRVS systems and the relevance and application of the vital statistics they produce. 10. Ensure the information produced by CRVS systems is used for policymaking. 11. Monitor and evaluate activities that strengthen the CRVS system in order to manage constraints and identify opportunities for progressing the activities in the CRVS Strategic Plan. 5

6 Introduction Timely and reliable vital statistics and cause-of-death data are of fundamental strategic importance to health systems. They provide health policymakers and managers with critical information for guiding policy, planning and resourcing of health priorities. The best source of these data is a complete vital registration system, commonly and most effectively established through civil registration (United Nations Statistics Division 2001; AbouZahr et al. 2007). Fiji recognised the value of civil registration and vital statistics (CRVS) systems and went through a lengthy and constructive process to strengthen their system. The process began tentatively, emerging from a history of domestic and international meetings and developments. However, it was not until after several pivotal events namely, key stakeholders attending the Brisbane Accord Group (BAG) workshop in February 2012, and attendance by Ministry of Health (MoH) personnel at the University of Queensland s Health Information Systems Short Course in September 2011 that significant progress was made. The MoH invited key stakeholders in CRVS, including the Fiji Islands Bureau of Statistics (FiBOS) and the Office of the Registrar General (RGO), to join with it to form a CRVS committee. This was a critical step in strengthening CRVS in Fiji. In this paper, we document the history of events, the achievements of the CRVS committee and the lessons learned. We begin by examining the importance of CRVS for Fiji, highlighting the integral role vital statistics play in addressing the imposing non-communicable disease epidemic. We then outline how the CRVS system in Fiji operates, and identify some of its strengths and weaknesses. After describing the events that led to the formation of the CRVS committee, we explore in detail some of the success stories and challenges it faces. Critically, we examine the key lessons learned from this experience, both as a means of reflection and learning for Fiji, and so that other countries might learn from these lessons and see the benefits of engaging in such a process. 6

7 The strategic importance of civil registration and vital statistics Why civil registration and vital statistics systems matter for health systems of any health system, which is to keep people alive and healthy for longer (WHO & HIS Hub 2010b). Civil registration systems are government-administrated systems used to record vital events including live births, deaths, foetal deaths, marriages and divorces. These permanent records have two main uses. First, they are personal legal documents that confer individual rights of identity, property and status. Second, and most importantly from a demographic and epidemiological perspective, they provide data that have the potential to serve as the main source of national vital statistics. Vital statistics are a key input for policymaking and planning in human development, and are essential for the effective operation of health systems. They inform policymakers of the size and characteristics of the population; of the number of live births over time, classified by various characteristics of the mother; and of deaths, classified by various characteristics of the deceased, especially age and sex. Such knowledge is invaluable for assessing and monitoring the health status of populations and planning interventions (Health Metrics Network 2008). Civil registration is arguably the most effective source of these vital statistics (UNSD 2001; AbouZahr et al. 2007; World Health Organization & Health Information Systems Knowledge Hub 2010a; WHO, HMN & HIS Hub 2012). One of the main advantages of civil registration is that it provides a continuous, permanent, compulsory and universal recording of the occurrence and characteristics of vital events pertaining to the population (UNSD 2001). Civil registration assists in calculating birth rates, death rates and other key health status indicators. In addition, when coupled with medical certification of cause of death using the principles and standards set out in the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (WHO 2010), it identifies trends in leading causes of death in a country. The vital statistics produced by civil registration systems are, therefore, the cornerstone of a country s health information system. Without this information, it is difficult for communities, governments, donors and multilateral organisations to effectively undertake and monitor the planning and impact of a whole range of social programs and health initiatives. Furthermore, if information is lacking on the number of births and deaths, and on sex, age and cause of death, it is difficult to achieve real progress towards the fundamental goal Global and regional drivers for civil registration and vital statistics Despite the obvious benefits of CRVS systems, many developing countries have dysfunctional and incomplete systems where births and deaths are seldom registered, and information on the cause of death (if it is indeed collected) is often unreliable. The failure to address these shortfalls is described by Richard Horton (2007), editor of The Lancet, as the single most critical failure of development over the past 30 years. However, vital statistics are finally overcoming decades of stagnation (Setel et al. 2007). The Millennium Development Goals (MDGs) flagged the urgent need for reliable, continuous and comparable vital statistics. At least six of the goals rely on accurate data on mortality and causes of death for monitoring progress (Setel et al. 2007). The global commitment to these goals created the momentum to improve birth and death data, a momentum being reinforced as attention shifts to the post-2015 agenda. More recently, the Secretary- General s Commission on Information and Accountability for Women s and Children s Health (United Nations 2011) highlighted the critical role of CRVS in monitoring infant, child and maternal mortality and recommended countries prioritise efforts to strengthen their CRVS systems. International agencies are also concerned about other aspects of the CRVS system that need strengthening, particularly birth registration. They emphasise the important links to human rights and individuals access to legal identity. In fact, countries that are signatories to the Convention on the Rights of the Child (UN 1989) are expected to set up systems to register the births of all children without applying discriminatory conditions. There is regional momentum for strengthening CRVS systems in the Asia Pacific as well. The United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) Committee on Statistics recognised the need for a CRVS improvement strategy in 2008, and in 2010 assigned ESCAP the task of developing an improvement plan (UNESCAP 2010a). UNESCAP then passed a resolution in 2011 calling for countries and development partners to support activities for strengthening CRVS 7

8 (UNESCAP 2010b, 2011). The High-level Meeting on the Improvement of CRVS in the region in December 2012, introduced the Making every life count initiative and established consensus on a draft Regional Strategic Plan (UNESCAP 2012a, 2012b). Civil registration and vital statistics for the Pacific region Vital statistics are especially important in the Pacific region, particularly in the health and development sectors. The region comprises 15 independent and diverse sovereign countries and 7 territories. Each relies on national, provincial or territorial statistical services to guide policy development and planning, to monitor progress of health system interventions, and to evaluate the outcomes and impacts of these interventions and policies. They also require reliable vital statistics to monitor trends and report domestically and internationally on demographic, social and development indicators. Although health and mortality data are collected extensively in Pacific Island countries, these data are rarely analysed or used (Kuartei 2005), as they are considered to be either incomplete or unreliable (Haberkorn 1997, 2009; Mathers et al. 2005; Taylor, Bampton & Lopez 2005; Brisbane Accord Group 2012). Over the last decade, these shortfalls have been exposed by the need to monitor progress on the MDGs, which has highlighted the difficulties faced by many countries to provide timely and recent figures (Haberkorn 2009). Regardless of these data shortcomings, there is a general acknowledgement that the Pacific region is undergoing a rapid and exaggerated health transition from communicable to non-communicable diseases (NCDs), with NCDs now contributing to significant amounts of premature mortality and morbidity (Khaleghian 2003; Taylor, Bampton & Lopez 2005; Snowdon 2011). The challenges faced to effectively monitor and combat this impending epidemic have further emphasised the need for better mortality and cause-of-death data. Such data can be produced through well-functioning routine registration systems. In fact, it has been posited that monitoring the spread and distribution of NCDs can only be achieved with reliable vital registration systems that count all deaths and reliably certify their causes on a continuous basis (WHO, HMN & HIS Hub 2012). The Pacific region is, however, responding to these challenges. The Ten-Year Pacific Statistics Strategy recognised CRVS as a key element for statistical improvement across the region. CRVS has attracted even greater attention and prominence through the formation of the Brisbane Accord Group (BAG) and its Pacific Vital Statistics Action Plan (BAG 2012). This initiative focuses on coordinating partners to support countries to improve the completeness and quality of their CRVS data. The Pacific Health Ministers meeting in the Solomon Islands in July 2011 welcomed the formation and goals of the BAG. The meeting recommended that CRVS be a regional priority. 8

9 Civil registration and vital statistics in Fiji Country context Fiji is an island nation in the south-west Pacific Ocean, located between Vanuatu and Tonga. Fiji s exclusive economic zone covers about 1.3 million square kilometres of the Pacific Ocean with 330 islands, of which one-third are inhabited. In the 2007 census, the population was , comprising 51 per cent males and 49 per cent females, with 29 per cent under 15 years. The ethnic composition is diverse: 57 per cent are Indigenous Fijians (itaukei), 37 per cent Indo-Fijian and 6 per cent others (including other Pacific Islanders, Chinese and those of European descent) (FiBOS 2010). As for many of its Pacific neighbours, this dispersed developing island nation is burdened by increasing rates of NCDs. According to MoH (2012) figures for Fiji, the top five NCD causes of death in 2012 (including diabetes mellitus, hypertensive illness, ischaemic heart disease, cancer and other forms of heart disease) account for 61.8 per cent of mortality. A snapshot of civil registration and vital statistics in Fiji Fiji has a longstanding civil registration system. Registration of births, deaths and marriages (BDM) is a legal requirement under the Births, Deaths and Marriages Act This Act still remains substantially the same. There are 3 divisional offices, 19 district offices and 18 assistant district registries catering for birth and death registration needs in Fiji. Registration is available in all centres. Numerous stakeholders contribute to the system as shown in Figure 1. Table 1 Key development indicators of Fiji Indicators Measure Year Source Comment/Notes Total health expenditure, public (% of Gross Domestic Product) UNDP 1 Life expectancy at birth (years) UNDP 1 Gradually increasing Infant mortality rate (per 1000 live births) Under-five mortality rate (per 1000 live births) MoH 2 MoH 2 Infant, child and maternal mortality rates have been halved since the 1960s 3 but currently fall short of the proposed Fiji targets for the Millennium Development Goals 4. Maternal mortality ratio (per live births) MoH 2 Sources: 1 United Nations Development Programme (UNDP) 2013; 2 Ministry of Health (MoH) 2012; 3 Ministry of Finance and National Planning 2004; 4 Asia Pacific Observatory on Health Systems and Policies

10 ITC Services (Govnet PATIS, BDM) National Vital Statistics Registrar General Bureau of Statistics Registration Provincial Office District Officers Towns, Village Data Sources Health 1. Divisional Hospitals 2. Sub-Divisional Hospitals 3. Health Centres 4. Nursing Stations Medical Officers, Nurse Practitioners Birth and Death Occurence Users of Statistics 1. MInisters 2. NGOs 3. Donors 4. Public 5. Researchers 6. Others General Public Figure 1 Structure of Fiji's civil registration and vital statistics system As well as providing a platform for the legal identity of its citizens, Fiji s CRVS system aspires to produce births, deaths and cause-of-death data that are complete, timely and of sufficient quality to be in demand and used for evidence-based decision-making by managers. Figure 2 depicts such a system, reflecting the uses of the vital statistics produced by civil registration in Fiji. Although the tree may appear healthy and productive, beneath the surface the foliage, roots, trunk and branches, and the nutrients supplying the foliage are failing. That is, the registration practices that support the system and the quality of the data compiled need strengthening so that the information produced is of greater value to users. 10

11 Fiji Civil Registration and Vital Statistics System Health data and information Causes of Death Mortality and Fertility Life Expectancy Infant, child, maternal mortality Communicable and non communicable diseases Specialist health topics: HIV /AIDS tuberculosis, cancer, diabetes Population information Inter-censal population information Births, deaths Estimated resident population Population projections Social information Ageing population and planning Educational and community planning Child and parental programs Individual use Identity confirmation Eligibility for social payments Births data Deaths data Causes of death data Economic information Population growth Ageing and economic impact Sub-regional growth and impact Legal use Identity confirmation Citizenship and passport Fraud prevention Legal Identity Birth and Death Registration Fiji Government Figure 2 How Fiji s civil registration and vital statistics system is used (Adapted from an Australian Bureau of Statistics image) Birth registration process Figures 3 and 4 demonstrate the process of birth notification and registration in Fiji. Both parents are responsible for registering the birth of a child, although alternative arrangements are permitted in the case of death, illness or where other legitimate circumstances render the parents unable to register. Under the Fiji Health Laws, all expectant mothers are required to have their child delivered in a hospital, where a Notification of Birth Slip is issued to the mother by the nurse/doctor to confirm the child s birth. The Notification of Birth Slip is the primary legal document and supporting evidence of a birth for parents to provide when registering a birth at the registry. Other personal documents such as a baptismal card or health card may also be used as evidence. Major hospitals in Suva, Lautoka and Labasa are linked with the BDM computer networking system and births in these institutions are recorded for registration purposes using this system. Written records are still stored and maintained, however, to provide a back-up source for the registry. Parents or informants must complete and sign the registration forms in the presence of the Registry Clerk. Children need to be registered within two months of birth (UNICEF 2005). However, no penalty is incurred for late registration until after one year. Births registered after two months must be made by a solemn declaration. Registration is free, but issuing a birth certificate incurs a prescribed fee. Birth registries are available in all centres (UNICEF 2005). 11

12 Birth occurs (in the community or in a health facility; includes births before arrival) Live birth Notification of birth completed 1. Parents 2. Bureau of Statistics 3. Registrar General 4. Archive (Original - white copy) (Yellow copy) (Pink copy) (Blue copy) Figure 3 Birth notification process Note: LBR Late birth registration, NBR New birth registration Fiji benefits greatly from having such a well-established birth registration process, which has the following noteworthy qualities. A standard birth notification and registration form ensures consistency of information and processes. The patient information system (PATIS) for recording all births in public hospitals is an online, centralised, web database system enabling data on births to be routinely collected throughout the system in a timely manner.the BDM computer networking system for registering all births in the country ensures that a consistent process is used. Nineteen district offices provide the public (including those in rural and remote locations) with access and the opportunity to register. Provincial officers in the district advocate and register births and improve completeness. Strong collaboration between district officers and village headman or turaga ni koro ensures greater advocacy and community understanding of the importance of registration and enhances coverage. 12

13 Produce Notification of Birth from Hospital (CLIENT) Lodgement (Child's Parents CLIENT) Check Requirements (REGISTRATION CLERK) Search and Verify Parents' Birth and Marriage Records (REGISTRATION CLERK) Produce Notification of Birth from Hospital (CLIENT) Produce Notification of Birth from Hospital (CLIENT) Vet Registration Forms/Attachment & Approve Payment for LBR $11.30 /NBR (SUPERVISOR) Capture Registration in BDM System (REGISTRATION CLERK) Printing of Certificate upon payment of fees (CASHIER) Dispatch of Certificate to CLIENT (DESPATCH CLERK) Figure 4 Birth registration process Challenges of birth registration The RGO registers approximately 40 per cent of births each year despite 100 per cent birth notification coverage by the MoH (MoH, FiBOS & RGO 2012). The completeness of birth registration therefore remains a challenge, particularly when compared to deaths. Issues also exist around the quality of information. There are many reasons for these challenges and some are highlighted below: The public generally lack awareness of the importance of birth registration and knowledge of the procedures. There are no tangible benefits or incentives for early registration. Consequently, parents will not register the birth until there is a benefit in doing so. For example, when formal identification through birth registration is required for the child to go to school, open a bank account or get a tax identification number. In Fiji, naming a child usually occurs two to three months after birth. This delays registration. A lack of coordination between the core agencies and registration procedural issues delay or limit registration. For example, the MoH issues a notification of birth to parents and the Registrar General. However, there are numerous requirements to be met before the RGO can register a birth (e.g. child s name, parents details etc.) and this hinders early registration. Access to registration services can be limited in rural areas, especially on remote islands. The registration offices are mainly located in urban areas, so parents from rural areas are restricted or prevented from registering a birth due to the expense of travelling to a registry office. The late penalty fee is minimal with no enforcement and therefore does not act as a disincentive for late registration. Unreported cases outside hospitals are not captured. Resources for provincial and district officers to promote, advocate, register and monitor registration are scarce. Flaws in the system and legislation make it vulnerable to cases of forged registration and this can lead to misinterpretation and inaccurate information. Numerous administrative problems lead to inaccurate information such as mismatched client details, duplicate records, validation issues, and falsified identities by people trying to seek medical care. 13

14 Cause of Death is known or can be reasonably determined based on history and clinical assessment Death occurs (Community or in a Health Care Facility includes DOA and DBA) Cause of Death is not known or suspicious Police are notified and investigate the case Post mortem is not conducted Post mortem is conducted Cause of Death Certificate completed Original (White) copy is sent to the District Office or Registrar General's Office within 3 days Relative copy (Green) is used to confirm death Police copy (Blue) provided to Police for Burial Order HIU copy (Pink) sent to Head Office MoH within 3 days Archive copy (Yellow) remains in the book as a permanent record Death Registered Undertaker, FNPF, Burial Servises Data entered to MCD Module (PATIS) is available for reports Stored appropriately and retained on site Figure 5 Death notification process Death registration process Fiji collects data on deaths through both the civil registration system, and through a MoH reporting system. Deaths cannot be registered by the civil registrar without a medical certificate of death. MoH policy requires a medical certificate for all deaths (both hospital Data Monitoring and Quality Checks undertaken quarterly Note: DBA dead before arrival, DOA dead on arrival, FNPF Fiji National Provident Fund, HIU Health Information Unit, MCD medical cause of death, PATIS patient information system and community deaths) and collates this data in its health information system. Monthly nurses reports and hospital discharge data are also routinely reconciled with the medical certificate of death data (Carter et al. 2010, 2012). Figures 5 and 6 demonstrate the process of death notification and registration in Fiji. 14

15 Data Entry Officer searches and verifies deceased's birth details and enters MCCD in BDM system Clients complete death registrations in accordance with MCCD details and add other information (spouse's name, etc) Registration clerk verifies details entered to ensure that registration is accurate Supervisor verifies and accepts registration in the BDM system Client signs and inserts date on completed registration form Registration clerk prints complete registration form and shows informat to verify particulars of death are correct Registration clerk advises informant that registration is complete and issues PIN of death registration Printing of certificate upon payment of fees (CASHIER) Dispatch of Certificate to Client (DESPATCH CLERK) Figure 6 Death registration process Note: BDM births, death and marriages, MCD medical cause of death, MCCD medical certification cause of death, PIN personal identification number Compared to births, death registration appears to achieve greater coverage and is more timely. A significant reason for this is the benefits to relatives and family members from the release of a death certificate. Property or monetary value of the deceased, for example, requires a legal document before it can be released to family or relatives. The following outlines some of the strengths of the death registration system in Fiji. Notifications are issued by MoH in a standard death notification form, which is also used by the private sector. All funeral services and burial sites require a death certificate before they can take place and this mandates people to register. Registration is completed within a month of a person s death to enable relatives to perform funeral services with minimal delay. This also ensures any superannuation or property rights from the deceased can be promptly claimed. The MoH has an operational electronic database (PATIS) that captures death notification effectively. Death registration is entered into the BDM system for storage, management and accessibility. There is medical certification of death and MoH uses up-to-date ICD-10 and Automatic Classification of Medical Entry (ACME) coding for causes of death. However, these processes require strengthening. There are mortality coders in Fiji, something many Pacific countries lack. These coders receive ongoing support from regional experts at the Queensland University of Technology. Monthly nurses reports and hospital discharge data are also routinely reconciled with the medical certificate of death data. Health data therefore have a good level of completeness for mortality. There is good coverage of community deaths. 15

16 Challenges of death registration Creating a complete and integrated system remains a challenge for registering deaths despite the system s many strengths. Some of these challenges are outlined below. Deaths are very well captured in the MoH (PATIS) system. However, there is no central database for coding the death. Only 60 per cent of all deaths are registered through the RGO. Deaths not reported are usually not captured. This includes deaths at sea and air. Using different editions of disease classification has made analysis of data over time difficult. Although no longer coding deaths, FiBOS was previously using ICD- 9, while MoH, who now code all deaths, use ICD-10. There is a need for additional coders, training on mortality and using the ACME tool. There are insufficient resources to maintain both PATIS and BDM systems. Mortality statistics are used primarily for legal and administrative purposes with minimal use of information for planning. MoH is able to generate reports on the occurrences but lacks a quality data audit system for coding. (Manual checks are being made for duplicates however.) Data-sharing procedures, particularly confidentiality practices, are poorly understood and no clear guidelines exist. Data sharing between agencies is therefore slow and untimely, often due to fears of breaching confidentiality or abuse of information. There are administrative issues that need to be resolved. For example, when birth registration is incorrect, death registration is also problematic. Hospitals also issue death notification based on the person s details recorded in the PATIS system. If the name entered in PATIS is wrong, this creates duplicates and registration issues for BDM. The late penalty fee is low and not enforced and therefore does not act as a disincentive for not registering. Access to registration services can be limited in rural areas, especially on remote islands. Although public health facilities are able to notify and report occurrence of births and deaths under the Public Health Act 1978, ensuring the private sector do the same is a challenge. Coordinating agencies and data systems: a major challenge Perhaps the biggest hurdle for birth and death registration in Fiji is the need for agencies to coordinate their activities and their data systems. Several key players operate in this field, including the MoH, the Ministry of Justice and Public Enterprises (MoJ), FiBOS, the Ministry of Provincial Development, and the RGO Births, Deaths & Marriages. They have defined roles within the registration system and several agencies have data systems to manage their operations. However, there is a lack of understanding of each other s roles, how they link (or should link) together, and there is no synchronisation of data systems. MoH s primary function in birth and death registration as required under the Act is to provide notification of the event and up-to-date statistics on new births and deaths. They are also the primary source for cause-ofdeath data. To enhance this and other data management processes, the MoH, with support from the Australian Agency for International Development (AusAID), invested in the PATIS as part of the Fiji Health Management Reform Project. This electronic system initially operated in selected health facilities across a distributed network architecture but was upgraded to a web-enabled platform in 2011, running in a central architecture accessible to all facilities on the government network (govnet). The investment in this particular information technology was extremely valuable for providing timely and routine data for Fiji. The MoJ is responsible for administering births, deaths and marriages under the Births, Deaths and Marriages Registration Act [Cap 49] and the Marriage Act [Cap 50] and maintains all records of these registered events in Fiji. It protects the legal entitlements of Fiji s citizens and residents and seeks to provide accurate and reliable data for planning and research. The provincial administrators and district officers are also empowered under the Act to perform duties and solemnise marriages on behalf of the Registrar General. Similar to PATIS, the MoJ s BDM system is a web- enabled, electronic registration system, and operates on govnet. It is accessible nationally from district offices and the RGO and is the sole source of registration statistics for the country. 16

17 While these two systems are invaluable for maintaining vital statistics and enabling their respective ministries to undertake their roles in civil registration, the two applications work in parallel with minimal collaboration between agencies and no data synchronisation. Both parties share manual records; MoH provides birth and death notifications and MoJ provides registered numbers for the country. However, until recently, neither agency was comfortable communicating and sharing its information electronically. This lack of communication and data sharing has lead to two different sets of vital statistics being generated for the country. Other agencies, integral to the CRVS system in Fiji include the FiBOS, the Government Information Technology and Computing Services (ITC) Department and the Ministry of Provincial Development. All are affected by this systemic lack of coordination and data sharing and all contribute to it. FiBOS role is to collect, compile, extract and analyse vital statistics. However, they obtain their data from both MoH and MoJ and these data are often conflicting. ITC s primary role is to provide high-level security to protect electronic BDM data and ensure it is not accessed by unauthorised personnel. It also assists with operating the network infrastructure of the two govnet systems, PATIS and BDM. The two systems are not linked and the ITC will need to be involved when integration begins. The Ministry of Provincial Development, among its many operations, performs the duties and functions of the Registrar General at the district level through its rural and urban agencies, but must coordinate its activities with the RGO. These agencies all have key roles and responsibilities. However, each agency has been doing so in isolation, duplicating the work and failing to reconcile national figures for better planning. It was not until several significant events, described below, that the agencies began to communicate more effectively and coordinate their efforts to overcome these obstacles. 17

18 Strengthening civil registration and vital statistics in Fiji Early activities ( ) Discussions on strengthening the CRVS system in Fiji began in 1999 during the AusAID-funded Fiji Health Management Reform Project. As part of this project, a Management Information Systems Plan was developed for the Ministry of Health, focusing on Fiji s broader health information system needs, of which CRVS are an integral component. Various assessments and initiatives followed (Annex A) and included: reviewing medical record practice and using health information across the health sector through Phase 1 of the Health Information Infrastructure Situational Analysis in 2005 preparing a draft health information development plan in 2005 assessing the completeness and accuracy of information used in the analysis of fertility and mortality in Fiji in Fiji also committed to a number of capacity-building activities, including training coders in ICD coding and training doctors in death certification. Although some of these activities focused on larger processes and did not target CRVS in a direct and systematic manner, they nonetheless provide early recognition of the need for CRVS strengthening, and early examples of efforts to begin this process. It was not until 2008 that activities to strengthen health information systems targeted CRVS directly. Employing the Health Metrics Network (HMN) Framework and Assessment, the Fiji Health Information Assessment highlighted CRVS as a key issue to be resolved. Research by Carter et al. (2010, 2012) confirmed this need, pinpointing key strengths and weaknesses of the system and creating a necessary evidence base for further action. Then, in 2010, a rapid assessment of national CRVS systems was conducted externally with the assistance of selected national staff, using the tool developed by the University of Queensland s Health Information Systems Knowledge Hub (HIS Hub) in partnership with the WHO (WHO & HIS Hub 2010a). The key findings from this assessment were that: a system was in place but awareness and advocacy of the system and its processes were clearly lacking Fiji has a BDM system that captures birth and death registrations but access to this system was only through the commissioner s office and national office people living in rural and peri-urban centres found it difficult to find a suitable place to register their case staff using the system needed further training in using the system and understanding its importance data sharing between core agencies was lacking, highlighting the great need for them to work together the national office did not submit any quality audits or data reports. Around the time of the rapid assessment, regional attention and efforts in the region were being harnessed with the formation of the Brisbane Accord Group (BAG) in December As mentioned earlier, this led to the development of the Pacific Vital Statistics Action Plan ( ) in April 2011, which was later endorsed by the Pacific Islands health ministers at their 2011 meeting. The plan sits under the framework of the Ten-Year Pacific Statistics Strategy and also forms part of the UNESCAP Regional Strategy for strengthening CRVS systems. These initiatives were timely for Fiji. Not only did they help draw the much-needed attention of policymakers and stakeholders to strengthening CRVS, they also ensured the necessary technical support for planning and action (BAG 2012). Momentum was building and in 2011, as part of its health systems strengthening exercise, the MoH developed its Health Information Policy and a five-year costed Health Information Strategic Plan. This recognised the important role health information plays as a building block for strengthening health systems. One of the key objectives of this plan was to improve vital statistics in the country. The plan was endorsed in December 2011 and implementation began in Through this exercise and the support of development partners, the MoH gained a better understanding of the role health information systems and vital statistics played in the country. An important lesson learned was the need for MoH to collaborate with other government departments such as the RGO, FiBOS and the ITC. In September 2011, several CRVS stakeholders, including from the MoH, attended the Health Information Systems Short Course in Brisbane. It was offered by the University of Queensland and supported by numerous development partners. This course further demonstrated the importance of health information systems, and CRVS in particular, and presented numerous tools and suggestions of ways to strengthen the system (HIS Hub 2013). 18

19 By the end of 2011, Fiji was poised to ramp up its efforts to strengthen CRVS. It had built capacity, interest and support within the relevant government ministries for change, particularly in the MoH, and along with development partners was ready to provide technical expertise and support. But it would take some concerted efforts and the determination of a core team of stakeholders in Fiji to bring about this change. Country ownership drives process forward ( ) In February 2012, CRVS stakeholders from Fiji attended a special BAG meeting aimed at Pacific countries with wellestablished CRVS systems, but facing similar issues with these systems. As part of the Pacific Vital Statistics Action Plan, the meeting aimed to get CRVS stakeholders from within countries to sit down together to map out a plan to further strengthen their systems. The BAG meeting recommended forming a CRVS committee. This was a key outcome and the committee was established in April Establishing a committee: challenges and successes The primary purpose of the CRVS committee was threefold. 1. Assess the status of Fiji s CRVS system. 2. Evaluate the efficiency and effectiveness of current procedures. 3. Evaluate the impact and effectiveness of the committee s outputs. Setting up an effective committee to achieve these outcomes was challenging and required a committed team of passionate staff (first from the MoH, and then from other department stakeholders) who recognised the importance of a stronger CRVS system and its benefits to Fiji. The following discussion outlines the process of establishing Fiji s CRVS committee, some of the issues encountered, and some practical solutions to overcome them. Engaging stakeholders The first steps in establishing a CRVS committee was to identify the stakeholders involved in civil registration and the production of vital statistics and to bring them together. Three key agencies MoH, RGO and FiBOS demonstrated early interest and commitment to the formation and participation in the committee; others were harder to engage due to competing priorities. Although not all stakeholders were present at all times, particularly those that provided the ICT (information, communication and technology) infrastructure and support to the BDM system, the three key agencies nonetheless decided that the strength of these core agencies was sufficient for the process to commence and for progress to be achieved. They hoped that other agencies might come on board at a later date. Once the MoH team was established, they conducted a situational analysis to examine the different operations and processes of the CRVS system. Various agencies were producing figures and it was important to determine which were the most accurate and representative. The analysis examined the different data sources, coding practices and mortality statistics produced over a defined period. It searched for discrepancies and inconsistencies in the figures and in the practices used to produce these figures by different agencies. It also sought to determine the responsibilities of the different agencies, in particular, who was responsible for producing the official figures on births and deaths. The analysis concluded that national statistics were the responsibility of FiBOS. FiBOS sourced these figures from the MoJ. However, the analysis also revealed that the MoH was likely to be the best source of data on births and deaths given that most births and deaths occurred in health facilities and medical staff are required to complete compulsory death certificates. The MoH database also routinely collects data on births and deaths. It was therefore likely that FiBOS was not accessing the best-available data on births and deaths. It became apparent, that all stakeholders should be brought together to examine these issues and discrepancies and determine solutions and a way forward. This was the impetus for establishing a CRVS committee and starting to communicate with all stakeholders. 19

20 Leadership and governance The support and commitment of the Minister and Permanent Secretary of Health was critical to the success of the committee. Although the health information system leadership team presented a clear advocacy case for strengthening the CRVS system and forming a CRVS committee, they were fortunate that the Minister and Permanent Secretary were quick to understand this need and provide support to the process. While communication got underway with other stakeholder personnel at an operational level, permission was given for MoH representatives to commence preliminary activities to get national numbers correct. Meanwhile, the Minister lobbied at the ministerial level with the other stakeholder agencies to support and commit their personnel and resources to the process. The Minister then granted all necessary resources and approvals for meetings and logistics and formed a representative committee. To ensure ongoing support from the Minister and Permanent Secretary, the MoH representatives provided regular updates on the committee s progress to demonstrate accountability and to keep the issue on the agenda despite competing priorities. The Minister has consequently been a strong advocate for CRVS locally, regionally and globally, and recently represented Fiji at the Global Summit on CRVS in Bangkok to share Fiji s experience in strengthening its CRVS system and to advocate for strong leadership on this issue. With a committee established, it was important to define a clear governance structure. Although all members had an active and equal role in the committee, in due course each member was assigned specific tasks. A management structure ensured both accountability to superiors in respective ministries and responsibility for outcomes, as outlined below. Communication Following establishment of the committee, reliable communication was vital to ensure attendance and participation. In the initial stages, the committee used only to arrange meetings and seek confirmation. However, this was not always effective. As such, the MoH secretariat would make calls to the various members offices and their extensions and left messages. Although tedious, this was an effective method for ensuring attendance. An initial call occurred a week in advance. A second reminder call came the day before the meeting, then a final reminder early in the morning on the day of meeting. This process demonstrated the MoH s commitment to the project, which drew positive feedback and enthusiasm from fellow stakeholders. Obtaining the mobile numbers of members after the initial meetings ensured even better communication. Meeting logistics and incentives Ensuring meetings were held at convenient times and in an accessible and comfortable location also improved attendance. Efforts were made to secure the MoH conference room for the initial meetings, which was air-conditioned and set up so that it was conducive for discussions. Meetings were held on Tuesdays from 11:00am to suit everyone s timetable. The scheduling at this time was generally successful. Members appeared fresher early in the week, and although Mondays were usually busy for everyone, Tuesdays had fewer competing priorities and so members were free to focus on CRVS. A friendly, open and relaxed atmosphere was encouraged at meetings. Once members arrived for the meeting, morning tea was served and time was allocated for informal discussions where members could discuss their progress and challenges before addressing these more formally in the meeting. This encouraged openness among committee members, particularly from those who were less likely to raise issues or points of interest in the format of a meeting. The embracing and collegial spirit created among the committee members was a significant enticement to attend meetings. After four successful meetings at the MoH, other stakeholder departments offered to host meetings at their respective offices. Not only did this enhance collegiality, but it also allowed members to see firsthand how CRVS activities were carried out in the different departments and learn valuable lessons in the process. Transportation can also be a problem when attending inter-agency meetings, particularly in government systems where vehicle booking and availability can be a problem. Various solutions were provided to ensure this never became an excuse for non-attendance. For example, the phone-call reminders ensured members had time to organise transportation early. Where possible, members were also encouraged to walk to the venue, especially when within a short distance. On 20

21 other occasions, committee members voluntarily paid their taxi fares to ensure they could attend and as a sign of their commitment to improving CRVS in Fiji. The other logistical challenges faced were resource constraints, many of which were overcome. For example, MoH made clerical staff available to print and copy minutes and ensure proper documentation and safekeeping of minutes and materials. MoH also set up a shared drive folder where all meeting minutes were stored. In addition, MoH provided electronic equipment where necessary, such as a multimedia projector, a laptop and power cords. Accountability and responsibility To make progress and achieve outcomes, members were all given tasks and responsibilities. Broadly speaking, each was assigned to conduct an assessment of the status of CRVS processes in their agencies, and each was to become the driver for change in their respective ministry. To ensure these responsibilities were acted on, members were made accountable for their duties. By providing the meeting minutes and progress updates to their supervisors, not only did it create an interest, trust and appreciation by supervisors of the work that was in progress, but it also motivated members to demonstrate progress, knowing that their bosses were aware of their responsibilities. Ownership and empowerment As mentioned above, each member was assigned a role in the committee, such as chairperson, co-chair, secretariat etc. Not only did this create an organisational structure for the committee, but the assignments also provided a sense of ownership of the process for members and empowered them to take an active role in activities to deliver timely outcomes. Members took pride in the strengthening processes, and despite their workloads, every member would make an effort to ensure they brought evidence of progress and achievements to the next meeting. In fact, making such efforts to bring data or to demonstrate issues faced by their department, created a virtuous circle of empowerment and enthusiasm. Analysing data, figures, and systemic gaps made the meetings particularly interesting for attendees and inspired them to present more of their challenges so that they could be resolved. The quantity of work was substantial but the collegial spirit, coupled with the support and encouragement from the chair and co-chair assured the team achieved unprecedented gains in CRVS for Fiji. Defining the committee s objectives, activities and outcomes As well as the broad goals presented earlier, the committee defined eight specific objectives to direct their activities. Specific objectives Determine how effective the civil registration system has been in the achievement of national coverage. Determine how efficient the vital statistics produced have been in the representation of national numbers. Conduct a rapid CRVS assessment. Identify the lessons learned from the experiences of members and from past assessments of the system; identify the issues and opportunities emerging from these reports. Determine the relevance and feasibility of the recommendations and assess the progress made towards achieving stated CRVS goals. Strengthen the national monitoring and evaluation capacity within the CRVS systems. Develop and design a prioritised action plan. Monitor and evaluate progress in implementing activities. Activities Studying background information and previous assessments Evaluating the efficiency, effectiveness, impacts and effects of previous assessments Conducting regular meetings with key stakeholders 21

22 Obtaining feedback, collating and documenting progress, and working together on problems and difficulties Collating meeting minutes and presenting them to senior management or supervisors Obtaining data from all agencies, analysing it and identifying gaps Identifying constraints and opportunities for the potential success of a strengthened CRVS system in Fiji Monitoring and evaluation Outcomes Examining the committee s potential: SWOT analysis Once the committee had established a representative, experienced and enthusiastic team which began examining CRVS processes in Fiji, the committee also explored potential challenges to their success as a working group (both internally and externally) and the strengths and opportunities they could take advantage of to overcome these challenges. The following discussion summarises some of these strengths, weaknesses, opportunities and threats (SWOT analysis) and details how these were used or overcome. Gained committee membership from MoH, FiBOS, RGO and ITC Established committee and commenced meetings April 2012 Held meetings fortnightly Conducted regular reporting of meeting minutes and action points to senior managers to ensure senior level engagement and accountability Won support from senior management (Minister of Health, Permanent Secretary Health, Permanent Secretary Justice, Government Statistician and Senior Government Officials from key agencies) Established mechanisms for support release of staff, provision of meeting venues, transportation Completed data comparison and gap identification reconciled death registration figures with notification figures Presented findings at the Holiday Inn CRVS meeting with BAG partners and planned future directions Made 19 recommendations for improvements to the CRVS system using the University of Queensland s s (HIS Hub) Prioritisation Tool (Mikkelsen 2012) Achieved progress in each of the 19 recommendations (see Table 2) Strengths Fiji was able to build on the findings from the various assessments due to the numerous strengths the country possesses and the potential of the committee. Strong leadership from the committee chairperson and co-chair was a key factor in the success of the committee. It ensured members of the committee remained motivated and felt supported undertaking their duties. This was further enhanced by the support offered from senior management such as Minister of Health and Permanent Secretaries. Relationship building between the stakeholders (MoH, MoJ, FiBOS) and maintaining a good working rapport with effective communication and knowledge-sharing played a pivotal role. Members felt comfortable confiding in each other, sharing their problems and presenting issues for which they required assistance. The strong bonds and confidence established between members created a sense of responsibility in each to take ownership and be accountable for their department s processes. It also helped provide solutions to many obstacles encountered during the meetings. Discussions were more fruitful and many opportunities for quick wins were uncovered. This provided the team with a great deal of satisfaction and the drive and desire for further progress. Another significant strength was the ICT infrastructure and systems in place. These systems allowed for better data analysis and evaluation. The two systems, BDM and PATIS, enabled the team to extract and compare data for the past 10 years. They then used formulating mechanisms and processes to clean, match and 22

23 reconcile data. Other useful communication tools such as s, phones and internet provided an effective mode of communication. The committee also developed a budget proposal early in the process. The foresight of the team to establish this in the initial stages of their work and the strength of the proposal meant it was approved and partial funding was secured in 2013 to continue the committee s activities. guidance for carrying out their activities. Much of this technical assistance was provided by the BAG and the University of Queensland s HIS Hub. The HIS Hub s CRVS assessment tools (WHO & HIS Hub 2010a, 2010b), CRVS resource kit (WHO, HMN & HIS Hub 2012) and related working papers (HIS Hub 2013) were of particular benefit. These tools were used to conduct the rapid assessment, to make and prioritise country recommendations and to work towards the CRVS Strategic Plan. Weaknesses Although the team used its strengths, there were also weaknesses to address. Initially, there was a lack of coordination, collaboration, communication and confidence in each other which undermined their ability to work together. For any progress to be achieved, it was critical that the stakeholders trusted each other and were willing to communicate and work together. Through strong leadership within the committee and with buy-in from senior management within ministries, members came to understand the importance of strengthening CRVS in Fiji and the gravitas of the issue for the government. The significance of what was being attempted created a sense of goodwill, trust and transparency. Despite this, there were issues with poor or nonattendance by key members at meetings, and even occasions where agencies were not represented at all. On most occasions, this was the result of competing work priorities, staff leave and transfers. Nevertheless, it hindered the ability of the committee to make key decisions for moving forward and was a significant challenge that stood in the way of achieving progress. For example, the committee depended on the ITC to provide BDM datasets and reports, without which no data analysis could be conducted. Similarly, if any other agency did not attend, the key role they played in describing their process could not be factored into making decisions. Untimely provision of reports and statistics from different agencies created further delays. Attendance issues and report deadlines were addressed by meeting in person with the agency or member responsible and working through these issues. Opportunities As the committee progressed with meeting their objectives, it explored opportunities to collaborate with agencies and development partners and seek technical The WHO s health information system country consultant was also on hand at CRVS meetings to introduce and provide guidance on the tools and methodologies. These globally recognised tools were used to allow the team to assess the system according to global standards and compare it against regional and global benchmarks. It also ensured any improvement goals aligned with these standards. While the team worked on processes and data, it was timely that a review of the National ICT System got underway through an independent company and that the CRVS committee s agenda was flagged as one of the highpriority items for that project. This would lead to further investment in the registration systems and processes with better coverage and accessibility for people. The team also had the Minister s High Level CRVS meeting in Bangkok in December 2012 and the Global Summit on CRVS, also in Bangkok in April 2013, as milestone dates to work towards. It therefore received support to ensure Fiji could achieve substantial milestones/progress in strengthening the CRVS system in time to share these achievements at these events. Threats The risk to the CRVS strengthening agenda and operations of the committee were many and contingencies were prepared to accommodate these threats. Staff movement, absence of staff (especially for training leave), and even attrition were critical and potentially detrimental to the project. Changes in leadership and country priorities threatened the continuity of the committee and its work. Natural disasters, for example, risked resources being shifted to address recovery and rehabilitation. That is, MoH services were moved to address public health activities and surveillance work, and health information priority shifted to collecting these datasets rather than CRVS work and critical mortality figures. 23

24 Favourable Unfavourable Strengths Weaknesses Internal Leadership and Management Support Team Work and Communication Ownership and Accountability Finance and Resources Previous Country Assessments Strong ICT Infrastructure Lack of Coordination between key agencies Poor attendance Competing Priorities Staff Transfers Data Extraction Opportunities Threats External Assistance from BAG, UQ HIS Hub and WHO External ICT Audit Yalamanchilli MInister's High Level Meeting Training and Capacity Building Attrition Change in Leadership Change in Country Priorities Natural Disasters Figure 7 SWOT summary Developing a country plan Equipped with a better understanding of the strengths and weaknesses of the CRVS system, Fiji then began its journey to develop its own country plan for strengthening CRVS effectively and efficiently. At a follow-up workshop at the Holiday Inn in Suva in October 2012, stakeholders and BAG partners discussed what the way forward involved. The CRVS committee presented a detailed analysis of its findings and outlined progress towards achieving objectives. This presentation was critical to establishing the country plan. The key milestones and achievements were categorised into five key areas, outlined in Table 2. 24

25 Table 2 Key milestones and achievements of the civil registration and vital statistics committee 1. Leadership, legalities and advocacy for health information systems and civil registration and vital statistics ü Gained support from senior management ü Identified key areas of the legislation (BDM Act) that needed reviewing ü Held advocacy workshops and meetings in various agencies ü Formulated sub-committee by the Permanent Secretary for Justice to review the Act and policies 2. Registration practice ü Conducted various onsite registrations in remote and rural villages ü Planned visits for other provinces ü Developed Registrar General s Annual Corporate Plan 2013 to include civil registration ü Published awareness brochures in the three dialects (Fijian, English and Hindi) ü Featured on radio talkback show (Radio Fiji Gold) on BDM registration issues ü Established a monitoring and evaluation framework ü Reviewed ICT infrastructure and systems 3. ICD-compliant practices ü Used ICD-10 coding standard with MoH as the sole coder for mortality ü Trained two doctors on coding of death certificates ü Conducted CRVS short course for agency staffs ü Developed a training plan for 2013 to conduct further training (coding, short course, data analysis and advocacy) ü Implemented a training plan (Divisional training in cause-of-death-coding, ICD-10 training, CRVS training) 25

26 4. Data quality, dissemination and access ü Checked data quality from 2013 using the analysing mortality level and cause-of-death data (ANACoD) tool ü Established coding audit mechanism ü Developed job description for coders and clerical officers ü Set up data-sharing mechanisms and structures ü Gained support from ITC to provide regular reports ü Provided quarterly analysed reports to management ü Shared data between agencies (FiBOS and RGOs) 5. Coordination and communication ü Established a working committee and terms of reference ü Built a team of committed and dedicated members ü Held regular meetings (one per month) ü Involved regional provincial officers ü Mapped medical and administrative boundaries in progress ü Exploring development of the CRVS Strategic Plan initiatives ü Engaged a broader stakeholder group (e.g. women, itaukei, strategic planning, finance and provincial development) The output from this meeting was consensus on a set of 19 recommendations across these five categories to guide the future direction of Fiji s strengthening activities (Table 3). The CRVS committee prioritised the recommendations using the University of Queensland s HIS Hub prioritisation tool (Mikkelsen 2012) and set out activities and processes to achieve them. The activities were fully costed so that the plan could be presented to senior officials to seek funding. 26

27 Table 3 The 19 recommendations of Fiji s country plan Category No. Recommendations 1 Review legislation Legal 2 Strengthen data sharing and define roles of each agency 3 Review policy - compliance and litigation 4 Increase registration in remote and difficult areas 5 Address late registration Registration practice 6 Mass catch-up of registration 7 Engage with broader group of stakeholders (incl. local community) 8 Improve monitoring of collection process 9 Invest in capacity building and infrastructure ICD-compliant practices 10 Improve death certification quality 11 Improve coding quality 12 Improve quality and reliability of data Data quality, dissemination, access 13 Improve human resources for data collection and analysis 14 Improve access to vital statistics data and reports 15 Build locals capability to use their own data/statistics Coordination 16 Revise the terms of reference of the committee to reflect greater commitment 17 Improve coordination - national and local 18 Examine and define roles and responsibilities in administrative processes 19 Agree on administrative boundaries A budget that will partially fund the country plan was approved for 2013, with funds earmarked for the RGO for improving registration; substantial funds set aside for the MoH to conduct ICD-10 coder training, cause-ofdeath training, CRVS training; and additional funds for FiBOS for data analysis and production. This funding is managed and incorporated within separate ministerial budgets, but is insufficient to cover all activities in the plan. Although existing resources (e.g. software, human resources) can be extended to cover some of the needs, the committee and ministries are seeking additional funding to ensure all activities can continue. 27

28 Table 4 Summary of country plan progress and next steps Category Legal Way forward Access technical assistance to review policies Plan and prepare workshop(s) Develop flyers in three languages Registration practice Develop media advertisement (content) Meet with provincial district officers Target remote areas (technology) ICD-compliant practices Provide training materials Seek QUT time and commitment Increase senior management s awareness Data quality, dissemination, access Improve data analysis and use Provide more training to staff Finalise terms of reference Coordination Develop and define roles and responsibilities Finalise health and enumeration area boundaries Develop and use GIS mapping Note: GIS geographic information system, ICD International Classification of Diseases, QUT Queensland University of Technology Progress is already underway across all categories of work. A sub-committee for review of legislation has been established. Registration practices are being strengthened with awareness flyers produced in itaukei language, mass registration drives planned and undertaken, and assessments are exploring CRVS infrastructure. Death certification and coding training have been undertaken and more are planned. Significant activities to improve data quality, dissemination and access are underway and coordination activities are advancing, including drafting a terms of reference for the committee. Applying the lessons to other Pacific nations For a country embarking on a journey to strengthen its CRVS system, the process can appear overwhelming. Progress is likely to be slow and complex and it may take many years to achieve desired outcomes. Although contexts differ from country to country in the Pacific region, the countries also share many features that are unique to the region. Other than geography and population size, many of them have similar political structures stemming from colonial rule. Pacific nations, 28

29 therefore, have a unique opportunity to apply the lessons learned from Fiji s success stories, challenges and adversities. Key lessons learned Lesson 1: Ensure country ownership of the strengthening process of the CRVS system. Lesson 2: Identify a CRVS champion(s) to drive the process forward and maintain momentum. Lesson 3: Conduct a rapid assessment that is country-led and engages the right stakeholders. The first three key lessons for Fiji are linked. For many years, external partners did assessments, held meetings and devised strengthening activities in Fiji with minimal involvement of local stakeholders. On numerous occasions, assessment findings and activity plans were poorly communicated to the relevant country stakeholders, severely limiting the potential for successful outcomes. When communicated, these assessments and plans were seen to be too aspirational and did not provide practical steps that could be implemented. It was not until several key events took place; namely, the 2012 BAG meeting and attendance of stakeholders at the Health Information Systems Short Course, that local stakeholders were galvanised and established a CRVS committee to take ownership of the process. These events also stimulated the interest of particular individuals or champions to take the lead in building and sustaining the momentum for change. This is an important lesson for development partners as well as for country stakeholders. Country ownership is critical to overcome resistance to change as it empowers the process from within. Part of the process of creating ownership is ensuring countries are heavily involved in the planning of assessments and strengthening activities even if they do not have the technical expertise. It also ensures that assessments are accurate and involve the right people and agencies. Furthermore, engaging local stakeholders builds local capacity to conduct these processes independently in the future. For these reasons, the CRVS committee decided to undertake a rapid assessment, independent of that performed in Not only was the 2010 assessment becoming outdated, members felt that assessing the system themselves was an important step for them to understand the challenges. They also felt they could engage the right stakeholders to improve the accuracy of the assessment. The rapid assessment tool developed by the University of Queensland s HIS Hub and WHO (2010a), provides clear guidance on undertaking an assessment and the elements of the system that should be reviewed. Using the rapid assessment or the more detailed comprehensive assessment (WHO & HIS Hub 2010b) allows countries to identify areas for strengthening. These activities should be prioritised to create a roadmap for progress (Mikkelsen 2012). Lesson 4: Engage development partners to provide technical support and assistance with planning. Although country ownership is paramount to strengthening CRVS systems, this does not mean that development partners should be sidelined. On the contrary, development partners were critical to the success of Fiji s strengthening activities, providing much-needed technical support and direction in a coordinated fashion under the BAG process. In fact, the BAG partnership was a primary catalyst in forming the committee and developing and implementing the country plan. However, the role of such agencies should always be one of partnership, by aligning and harmonising their activities behind country priorities. Lesson 5: Engage stakeholders and establish a CRVS committee to: collaborate, communicate and document processes ensure strong leadership and senior management support. Because CRVS systems operate over multiple sectors, engaging stakeholders and ensuring collaboration and communication between these partners was vital. Establishing a CRVS committee facilitated collaboration. As outlined earlier, creating a supportive environment that was conducive to working together assisted this collaboration. Strong leadership to drive the agenda forward also enhanced the process. But progress would never have been achieved without the support of senior management who provided resources and guidance where needed, and allowed staff to attend meetings and assess their respective departments. Lesson 6: Establish guidelines and processes for sharing data and knowledge between agencies and ensure this sharing occurs. 29

30 A significant component of collaboration and communication was data and knowledge sharing. For Fiji, many agencies were initially reluctant to share data and information, making effective coordination of CRVS processes particularly challenging. Establishing trusting relationships between stakeholders helped overcome personal insecurity over data sharing. A useful mechanism for embedding and formalising this trust between agencies was through memorandums of understanding. Lesson 7: Identify country strengths and quick wins and build on these. When embarking on a process of strengthening a country s CRVS system, identifying where to focus initial efforts can be perplexing. Fiji learnt that it was important to identify strengths in their system and build on these early. Linked to this was the need to identify simple opportunities for easy gains, or quick wins. Focusing on the strengths and quick wins created a positive message about the system and ensured members were encouraged by their activities, which could otherwise appear overwhelming. It also ensured that some significant progress could be made in the early stages of the work program to demonstrate progress. Lesson 8: Strengthen technical elements of the CRVS system alongside broader systemic issues (e.g. staff training/capacity building, standardised processes). This key lesson may appear obvious, however, it is important to highlight. Most of the lessons learned address important broader systemic challenges. Strengthening CRVS also requires strengthening the technical elements of the system and building capacity to collect, analyse and interpret data and make it useful and meaningful. Investing in staff training on statistical and CRVS practices was one way Fiji strengthened the technical elements of their system. Another was to standardise CRVS practices, particularly for coding, where different ICD classification methods were being used. Lesson 9: Advocate and increase awareness of the importance of CRVS systems and the relevance and application of the vital statistics they produce. A significant component of Fiji s program to strengthen CRVS has focused on informing the population about CRVS and advocating its importance. For the system to work effectively, the users (e.g. policymakers) and producers of vital statistics and the beneficiaries of the system (i.e. the population) need to understand how the system benefits them. This encourages greater registration coverage and better quality data and information. In particular, policymakers need to appreciate how investing in strengthening CRVS will ultimately assist them in their roles to improve the health and development of their nation. Lesson 10: Ensure the information produced by CRVS systems is used for policymaking. Perhaps the best way of advocating for stronger CRVS systems is to ensure the information they produce is used in policymaking. This ensures that users of this information, particularly policymakers, appreciate its value. In Fiji, information produced by the CRVS system is already being used for decision-making and allocating resources. Not only is this a positive development for good policymaking in Fiji, it also highlights the importance of the CRVS system and encourages support for additional strengthening activities. Lesson 11: Monitor and evaluate activities that strengthen the CRVS system in order to manage constraints and identify opportunities for progressing the activities in the CRVS Strategic Plan. Finally, an important lesson from the Fijian experience has been to ensure continuous progress of the prioritised and mutually agreed activities in the CRVS Strategic Plan. To progress, it is critical that constraints or obstacles to progress are recognised and managed, and that capacity-building opportunities are identified so that gaps can be addressed. The CRVS committee in Fiji identified methods for monitoring and evaluating CRVS strengthening activities, including the following. Develop a template for recording committee meeting minutes, action items, and responsibility and time frames for completing action items. Report monthly on activities at committee meetings. Follow up meetings with responsible officers on action items based on scope and timeliness. Analyse data from the three agencies to identify discrepancies, challenges and progress. Provide briefs to senior management (i.e. Permanent Secretary, Minister) to keep them informed of progress and challenges. 30

31 Refine activities with SMART (specific, measurable, achievable, relevant and time-bound) indicators. Conduct a SWOT analysis of implementation activities that are lagging. Engage in collaborative brainstorming with all stakeholders to identify and resolve obstacles and challenges. Identify milestones within planning and monitoring frameworks and ensure key achievements are formally acknowledged. Each country will develop its own mechanisms for monitoring and evaluating its activities, and these should be established during or immediately after proposing activities. This will inform the design of activities and allow sufficient time to arrange for resources and personnel prior to implementation. When done correctly, monitoring and evaluation strengthens the basis for managing the results, fosters learning and knowledge generation within agencies, and ensures public accountability. 31

32 Conclusions Reliable and comprehensive vital statistics are a necessity for guiding health policy and planning, and are essential for health systems strengthening. CRVS systems are undeniably the most effective source of these data. Information on births, deaths and causes of death produced by such systems is particularly important for countries of the Pacific region dealing with a rapid epidemiological transition from communicable to noncommunicable diseases. Fiji recognised the important role CRVS systems play in producing timely and reliable vital statistics, and ultimately in improving the health and wellbeing of its citizens; it therefore seized the opportunity to strengthen its CRVS system. The key driving force behind Fiji s success to date has been the establishment of a CRVS committee made up of a select group from key stakeholder agencies to drive the process forward. Not only did this initiative bring partners together so that they could collaborate and construct a coordinated strategy for improvement, but importantly, it ensured the process was country-owned. Country ownership should not be understated. In Fiji s experience, it was this factor and the presence of local champions who drove the process, which led to significant change and progress being achieved. Once a country takes ownership of the process, development partners can align and harmonise their efforts behind country initiatives and provide technical support as required. This was indeed the experience in Fiji. Accessing technical expertise from development partners remained a critical component to the success of the committee and should not be overlooked regardless of the stage a country has reached in its strengthening agenda. However, the relationship in this case was a collaborative one where the country owned the process and was facilitated by partners rather than instructed by them. In fact, both development partners and donors alike, found it easier and more appropriate to assist Fiji in this way, with the country taking the lead and providing a strategic plan to align behind. This working paper attests to the efforts that Fiji s CRVS committee has made to strengthen its CRVS system. Reflecting on this process has revealed some valuable lessons on how to use the system s strengths and address some of its many challenges. Of course, other Pacific nations poised to strengthen their CRVS systems will be inclined to develop their own strategies and customised approaches. However, while each country across the Pacific is distinct from the next, there are also many challenges that are common but unique to the Pacific region where the lessons from Fiji can be applied. It is hoped therefore, that the Fijian experience of strengthening its CRVS system can offer valuable lessons for other Pacific nations. In this way, they too can begin to improve their systems and produce the timely and reliable vital statistics so necessary for policymakers to make effective decisions on the health and wellbeing of their citizens. 32

33 Appendix A: Early history of civil registration and vital statistics strengthening in Fiji Assessment/Study/Article Year Focus Fiji Health Management Reform Project Milestone 021 Management Information System Plan Health Information Infrastructure Situational Analysis (Phase 1) 1999 Developing a Management Information System Plan for the MoH (funded by AusAID) This was part of the Fiji Health Management Reform Project which began in Reviewing the health information infrastructure, medical record practice and general use of health information across the health sector Draft Health Information Development Plan An assessment of the completeness and accuracy of information used in the analysis of fertility and mortality in Fiji 2005 Developing a Health Information Development Plan 2006 Assessing the completeness and accuracy of information used to analyse fertility and mortality in Fiji Fiji Health Information Assessment 2008 Raising awareness on the importance of health information systems at governmental level, between health information producers and users Introducing the HMN Framework and Assessment Tool to improve health information sharing, analysis and use Exploring the views of health information stakeholders on the status of health information systems in Fiji and capturing recommendations for improvement Rapid assessment of national civil registration and vital statistics systems 2010 Reviewing standards of country practices in CRVS Providing an overview of how well or poorly a country s overall system is functioning Facilitating communication/discussions on various aspects of CRVS systems among responsible organisations/staff 33

34 References AbouZahr, C, Cleland, J, Coullare, F, MacFarlane, SB, Notzon, FC, Setel, P & Szreter, S on behalf of the Monitoring of Vital Events (MoVE) writing group 2007, Who counts? 4: The way forward, The Lancet, vol. 370, no. 9601, pp Asia Pacific Observatory on Health Systems and Policies 2011, The Fiji islands health system review, World Health Organization (WHO), Health Systems in Transition (HiT), vol. 1, no. 1. Brisbane Accord Group 2012, The Brisbane Accord Group and the Pacific Vital Statistics Action Plan ( ): Outline document, BAG, Brisbane/ Noumea, viewed 10 February 2013, < VITAL-STATS-OUTLINE-FINAL.pdf>. Carter, KL, Rao, C, Lopez, AD & Taylor, R 2010, Routine mortality and cause-of-death reporting and analysis systems in seven Pacific Island Countries, Document Note series no. 8,, University of Queensland, Brisbane, viewed 17 March 2012, < HISHUB-DN8-Full-05-WEB-27Feb12.pdf>. 2012, Mortality and cause-of-death reporting and analysis systems in seven Pacific Island Countries, BMC Public Health, vol. 12, p Fiji Bureau of Statistics 2010, Fiji facts and figures as at 1st July 2010, FiBOS, Suva, viewed 5 March 2013, < pdf>. Haberkorn, G 1997, A sea of islands a myriad of indicators: on the interface between demography and planning in the Pacific Islands, Asia Pacific Viewpoint, vol. 38, no. 3, pp , Monitoring MDG progress in Pacific Island countries data availability, quality and access, ESCAP/ ADB/UNDP Pacific MDG Workshop: Taking stock, emerging issues and way forward, March 2009, Nadi, Fiji Islands. 2013, Publications and tools, Health Information Systems Knowledge Hub, viewed 4 March 2013, < uq.edu.au/hishub/publication-tools>. Health Metrics Network 2008, Framework and standards for country health information systems, 2nd edition, World Health Organization (WHO), Geneva. Horton, R 2007, Counting for health, The Lancet, vol. 370, no. 9598, pp Khaleghian, P 2003, Non-communicable diseases in Pacific Island countries: disease burden, economic costs and policy options, Secretariat of the Pacific Community and World Bank, Noumea. Kuartei, S 2005, Health care plans and dust collection in the Pacific, Pacific Health Surveillance and Response, vol. 12, no. 2, pp Mathers, CD, Fat, DM, Inoue, M, Rao, C & Lopez, A 2005, Counting the dead and what they died from: an assessment of the global status of cause-of-death data, Bulletin of the World Health Organization, vol. 83, no. 3, pp Ministry of Finance and National Planning 2004, Millennium Development Goals: Fiji National Report, National Planning Office, Fiji Ministry of Finance and National Planning, Suva, viewed 5 March 2013, < MDG%20report.pdf >. Ministry of Health 2012, The Ministry of Health Annual Report 2012 (Provisional), Fiji Ministry of Health, Suva. Ministry of Health, Fiji Islands Bureau of Statistics & Office of the Registrar General 2012, Civil registration and vital statistics workshop: Improving Fiji s vital statistics together, Power Point slides, Fiji MoH/FiBOS/RGO, Suva. Mikkelsen L 2012, Strategic planning to strengthen civil registration and vital statistics systems: guidance for using findings from a comprehensive assessment, Working Paper Series, no. 23, Health Information Systems Knowledge Hub, University of Queensland, Brisbane, viewed 17 March 2012,< docs/wp23/hishub-wp% %20oct.pdf>. Setel, PW, MacFarlane, SB, Szreter, S, Mikkelsen, L, Jha, P, Stout, S, & AbouZahr, C on behalf of the Monitoring of Vital Events (MoVE) writing group 2007, A scandal of invisibility: making everyone count by counting everyone, The Lancet, vol. 370, no. 9598, pp

35 Snowdon, W 2011, Challenges of noncommunicable diseases in the Pacific Islands: the need for evidence and data, Asia-Pacific Journal of Public Health, vol. 23, no. 1, pp Taylor, R, Bampton, D & Lopez, AD, 2005, Contemporary patterns of Pacific Island mortality. International Journal of Epidemiology, vol. 34, no. 1, pp United Nations 1989, United Nations Convention on the Rights of the Child, Article 7, United Nations, New York. 2011, Keeping promises: Measuring results. Every Woman Every Child, United Nations Commission on Information and Accountability for Women s and Children s Health, United Nations, New York. United Nations Children s Fund 2005, Birth registration in the Pacific Part II - Regional workshop on enhancing birth registration: Fiji, Kiribati, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu and Timor-Leste, UNICEF Pacific Office, Suva, viewed 3 March 2013, < pacificislands/br_report_part2.pdf>. United Nations Development Programme 2013, Human development report The rise of the south: human progress in a diverse world, UNDP, New York, viewed 15 March 2013, < EN_complete.pdf>. UNESCAP see United Nations Economic and Social Commission for Asia and the Pacific 2010a, Report of the committee on statistics on its second session, Bangkok, December 2010, UNESCAP, Bangkok. 2010b, Development of a regional programme for the improvement of vital statistics in Asia and the Pacific, Paper presented at the second session of the Economic and Social Commission for Asia and the Pacific Committee on Statistics, Bangkok, Thailand, December 2010, UNESCAP, Bangkok, viewed 22 February 2013, < United Nations Economic and Social Commission for Asia and the Pacific 2011, Improvement of civil registration and vital statistics in Asia and the Pacific, Resolution 67/12, UNESCAP, Bangkok. United Nations Economic and Social Commission for Asia and the Pacific Committee on Statistics 2012a, Outcome statement: Well-functioning civil registration and vital statistics systems in Asia and the Pacific by 2020, Bangkok, Thailand, December 2012, UNESCAP, Bangkok, viewed 22 February 2013, < Outcome-Document-FINAL.pdf>. United Nations Economic and Social Commission for Asia and the Pacific Committee on Statistics 2012b, Regional strategic plan for the improvement of civil registration and vital statistics in Asia and the Pacific, 3 December 2012 Draft, ESCAP Statistics Division, UNESCAP, Bangkok, viewed 22 February 2013, < stat/crvs/high-level/regional-strategic-plan pdf>. United Nations Statistics Division 2001, Principles and recommendations for a vital statistics system, Revision 2, Series: M, No. 19/Rev. 2. United Nations, New York, viewed 27 February 2013, < publication/seriesm/seriesm_19rev2e.pdf>. WHO see World Health Organization World Health Organization 2010, International statistical classification of diseases and related health problems, 10th revision, World Health Organization, Geneva, viewed 22 February 2013, < icd/en/>. World Health Organization & Health Information Systems Knowledge Hub 2010a, Rapid assessment of national civil registration and vital statistics systems, WHO, Geneva, viewed 27 February 2013, < hishub/docs/wp02/wp_02.pdf>. 2010b, Improving the quality and use of birth, death and cause of death information: Guidance for a standards-based review of country practices, WHO, Geneva, viewed 10 February 2012, < au/hishub/docs/wp01/wp_01.pdf>. World Health Organization, Health Metrics Network & 2012, Strengthening civil registration and vital statistics for births, deaths and causes of death: resource kit, WHO, Geneva, viewed 10 September 2012, < ResourceKIt_active_content.pdf > 35

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37 The Knowledge Hubs for Health Initiative The Health Information Systems Knowledge Hub is one of four hubs established by AusAID in 2008 as part of the Australian Government s commitment to meeting the Millennium Development Goals and improving health in the Asia and Pacific regions. All four hubs share the common goal of expanding the expertise and knowledge base to help inform and guide health policy. The Knowledge Hubs are funded by AusAID s Strategic Partnership for Health Initiative. The University of Queensland Aims to facilitate the development and integration of health information systems into the broader health system strengthening agenda, and increase local capacity to ensure that cost-effective, timely, reliable and relevant information is available. The Health Information Systems Knowledge Hub also aims to better inform health information systems policies across Asia and the Pacific. Human Resources for Health Knowledge Hub The University of New South Wales Aims to contribute to the quality and effectiveness of Australia s engagement in the health sector in the Asia Pacific region by developing innovative policy options for strengthening human resources for health systems. The hub supports regional, national and international partners to develop effective evidence-informed national policy-making in the field of human resources for health. Health Policy and Health Finance Knowledge Hub The Nossal Institute for Global Health (University of Melbourne) Aims to support regional, national and international partners to develop effective evidence-informed national policy-making, particularly in the field of health finance and health systems. Key thematic areas for this hub include comparative analysis of health finance interventions and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacific. Compass: Women s and Children s Health Knowledge Hub Compass is a partnership between the Centre for International Child Health, The University of Melbourne, Menzies School of Health Research and Burnet Institute s Centre for International Health. Aims to enhance the quality and effectiveness of women's and children s health interventions and focuses on supporting the Millennium Development Goals 4 and 5 improved maternal and child health, and universal access to reproductive health. Key thematic areas for this hub include regional strategies for child survival; strengthening health systems for maternal and newborn health; adolescent reproductive health; and nutrition.

38 The Knowledge Hubs for Health are a strategic partnership initiative funded by the Australian Agency for International Development