Monitoring trends in causes of death – India and the Million Death Study

The United Nations Sustainable Development Goals for 2030 include around 15 targets for mortality-related indicators.  The “gold” standard method for monitoring mortality and causes of death is a well-functioning civil registration system in which every death certificate has a medically certified cause of death. Unfortunately, in almost all low-income countries, and some middle income ones, death registration systems do not function well enough to produce data for reliable mortality statistics.  The graph below from our 2017 WHO World Health Statistics report ( shows that around half  of deaths worldwide are registered in a national system with medical certification of cause of death. Not all of these deaths are reported to WHO: about 40 % of global deaths are currently reported to the WHO Mortality database, which collects information on registered deaths and their causes from Member States which have them. Even fewer deaths have a meaningful cause of death code (ICD code), with many in some countries coded to ill-defined causes, symptoms, or non-informative immediate causes such as respiratory failure or heart failure.

The main gaps  in terms of reporting to WHO are China and India, who report only data from their sample registration systems. China has very substantially expanded its sample registration system over the last decade and the per cent of deaths registered with cause of death has increased from 9% in 2005 to over 60% in 2015.

India has a death registration system with medically certified cause of death which essentially captures mostly deaths in urban hospitals, a relatively small proportion of the more than 1 million deaths annually in India. Over the last 10 years, the Indian Registrar General has collaborated since 2001 with the Centre for Global Health Research in Toronto, Canada,  headed by Professor Prabhat Jha, to implement the Million Death Study (MDS) to obtain nationally representative data on causes of death in India. The MDS surveys a national sample of 1.3 million homes within the Sample Registration System (SRS), a continuous demographic surveillance system in operation since 1971.

The MDS uses a modified version of the 2011 WHO verbal autopsy (VA) questionnaire to obtain information on deaths from household members or close associates of people who have died. This questionnaire  uses structured checklist questions about key symptoms and a half-page local language narrative that captures events and their chronology.  Each verbal autopsy is assigned to two of 404 trained physicians, and they classify the underlying cause of death according to the WHO International Classification of Diseases 10th revision (ICD-10) using strict coding guidelines. Differences in diagnosis are reviewed and if agreement is not reached, a senior physician makes the decision (in about 10% of VAs).

Clearly, recall of relevant symptoms may be poor, and some causes of death are much more difficult to distinguish by events and symptoms than others. So VA-based diagnoses tend to have variable and higher uncertainty at the individual level. But in the absence of better data at population level, they do provide useful results for monitoring mortality trends and major causes of death of public health importance.

The Million Deaths Study data are used by my unit at WHO and our academic collaborators as a major input to the estimation of trends and distribution of causes of neonatal, infant and child deaths, as well as the overall age-specific causes of death for India for years 2000-2015, available on the WHO website as part of our Global Health Estimates 2015 (

Last week, the Lancet published a detailed analysis of the MDS results for trends in cause-specific neonatal and 1–59-month child mortality in India from 2000 to 2015 prepared by Prabhat Jha and the Million Death Study Collaborators (who include myself and our key academic collaborators in preparing the WHO-MCEE  and GHE2015 child cause of death estimates). The paper is available at

The Lancet, 380 (2017) . doi:10.1016/S0140-6736(17)32162-1

Among other findings, the study found that for children aged 1-59 months, mortality rates from pneumonia and diarrhoea have fallen by more than 60%. Improved female literacy rates, schemes paying women to deliver babies in hospitals and an increase in spending on public health by the Indian government have all contributed to the falling death rates. Mortality from vaccine-preventable diseases such as measles and tetanus have also fallen substantially. For babies under 1 month of age, mortality rates have fallen but at a slower rate (3.4% per year) than for the 1-59 month age group (5.9% per month). Mortality rates for prematurity or low birthweight have actually risen.

The U.N.’s Sustainable Development Goals seek to end the preventable deaths of newborns and children under five, with countries aiming to reduce infant mortality to at least as low as 25 per 1,000 live births by 2030. To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1–59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1–59 months is feasible. Additional attention to prematurity and low birthweight is required.

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