Mozambique: Post-Census Mortality Survey

Mozambique: Post-Census Mortality Survey Elisio Mazive Instituto Nacional de Estatistica MOZAMBIQUE

Outline of Presentation • Motivation for post-census mortality survey • Mozambique 2007 population census • Post-census mortality survey • Objectives • Methodology • Outputs • Policy implications

Motivation for PCMS • Need for accurate and reliable mortality Indicators • Lack of fully functioning VR systems • Opportunity for PCMS following 2007 population census. • The DHS and censuses do not provide cause-specific mortality indicators.

Filling a Major Void • Introducing a mortality survey linked to the 2007 population census was viewed as a way to obtain critical information to better guide planning and priority setting for health services at the national and provincial levels. • As far as we know, this is the world’s first such post-census mortality survey.

Mozambique Post-Census Mortality Survey • Designed to measure cause-specific mortality at the national and provincial level by following up deaths recorded in the 2007 census, in sampled areas, with ‘verbal autopsy’ interviews.

Mozambique 2007 Population Census • Included a question on household deaths in the previous 12 months • Name, age and sex of the deceased • For women ages 12-50, asked if it was maternal related death. • While mortality rates can be derived from the census, specific causes (e.g. HIV/AIDS, TB, malaria, injury, diarrhea, and respiratory infections) cannot be determined from the census alone.

Post-census mortality survey Overview • A sample of census enumeration areas (EAs), representative at the national, urban/rural, and provincial level, were selected. This formed the “death frame.” • All households reporting a death in the sample EAs were followed-up with a verbal autopsy form. • A team of trained doctors reviewed the verbal autopsies and assigned and coded a cause of death following ICD-10 procedures.

Survey Objectives • Provide reliable, representative cause of death data not available from any other source. • Feasible, reliable community-based approach to measure cause-specific mortality and other demographic and social indicators derived from the census.

Key Survey Participants • National Institute of Statistics • National • Provincial offices • Ministry of Health • National Institute of Health

Pilot of Post-Census Mortality Survey • Took advantage of the pilot census conducted October 1-15, 2006 to pilot the post-census mortality survey fieldwork. • Objective of the pilot was to test the logistics, processes, and financial feasibility of a post-census mortality survey.

Lessons From the Pilot Problems • Incompleteness of death reporting in pilot census. • Out of scope deaths reported in pilot census. • Problems linking census death, verbal autopsy, and cause of death coding files (inconsistencies in geographic codes).

Lessons From the Pilot Solutions Refined wording of mortality module of census form. Mortality survey staff from helped to strengthen the census training of trainers. Introduced unique identification variable for each death to be carried through all survey stages

Sampling Approach • Death frame constructed from a sample of enumeration areas (EAs) in the updated cartographic database. • Approximately 18,000 deaths were identified from the census in the selected EAs. • For each death information was extracted from the census form and entered into a database. • Every household in database was followed up in mortality survey.

Fieldwork & Death certification • Training of verbal autopsy interviewers done provincially. • Verbal autopsy fieldwork. • Training of medical doctors on ICD certification & coding. • Cause of death certification and coding. 8 months 2 months

Post-Census Mortality Survey Outcomes • Leading causes of death by age and sex at national, urban/rural, and provincial levels. • Leading causes of neonatal, infant, and under 5 deaths. • Maternal mortality – direct, indirect (AIDS-related separately identified)

Outcomes (continued) • Health service utilization in period before death – type and treatment. • Place of death. • Cause-specific Mortality rates by age and sex at national, urban/rural, and provincial levels.

Bonus • The post-census mortality survey is being used to adjust mortality data from the census, leading to higher quality census results. • Specifically, the mortality survey revealed that nearly 1 in 4 of census reported deaths (in the previous 12 months) were outside the reference period.

Challenges • A reasonably high quality census is essential. Errors in the census, in terms of cartography or data collection, make the post-census mortality survey more difficult. • Survey is highly dependent on census timetable for fieldwork and analysis. • Multistage structure of survey creates data management challenges. (DF+VA+DC).

Where does Mozambique go from here? • Increased awareness in Ministry of Health of the importance of classifying deaths according to ICD procedures. • First report analyzing mortality fractions will be released soon. • Second round of analysis will incorporate census results (denominators) and include mortality rates. • Sample areas from the mortality survey could be utilized in an intercensal mortality survey.

Policy Impact of Survey Results • Serve as a means for measuring the impact of scaled-up health initiatives that aim at reducing mortality (baselines). • Provide national mortality burden estimates for Ministry of Health budgeting & planning. • Provide indicators for: Millennium Development Goals; UNGASS; UNAIDS; PEPFAR, and the Global Fund to Fight AIDS, TB and Malaria; Poverty Reduction Strategies Indicators; The Safe Motherhood Initiative; Roll Back Malaria; Stop TB; The President’s Malaria Initiative.

Funding of Post-Census Mortality Survey • PEPFAR (USAID)……...…$ 2.5 million • UNICEF…………..…......…$ .35 million • Technical assistance provided by MEASURE Evaluation and U.S. Census Bureau, and CDC.

THANK YOU

Mozambique: Post-Census Mortality Survey