9.3.1 The health of the population is a matter of serious national concern. It is highly correlated with the overall development of the country. A healthy population is a developmental goal by itself though it is also a necessary ingredient for the other wider goals of social and economic development. India’s health system seems to be currently at cross roads with major changes occurring in the morbidity and mortality patterns. Some of these changes are consequent to the demographic transition, which is accompanied by changes in the age structure of the population but most of the changes are due to the control of major communicable diseases. Since independence, there have been significant changes in health conditions and the composition of the health sector and simultaneously major transformations have occurred in knowledge and technology, as well as in the political and economic environment. Life expectancy at birth has risen from 32 years at the time of independence to 61 years in 1996. The infant mortality rate (IMR), a sensitive indicator of both socio-economic development and use of health services, has been reduced from 146 deaths per 1000 births in the 1950s to 72 in 1998. Yet, reductions in the IMR have stagnated in the 1990s, and the nutritional status of children under five years has improved very slowly over the last 20 years. Nearly half of all children under five are malnourished, and anaemia remains a problem for about three-quarter of the children under three, and half of all women in the reproductive ages. New health threats are stretching the capacity of the health system to respond: it is estimated that 3.7 million people are living with HIV and the virus has now spread beyond highly susceptible groups to the general population in some States. Although, overall health conditions have improved in India, the current challenges are enormous. India was one of the first countries in the world to intervene in population control as a national programme in 1951. Although the total fertility rate fell from 6.0 in the 1960s to 3.3 in 1999, it remains higher than in most other Asian countries. In the context of growing uncertainties in the outcomes of various current healthcare programmes and newer diseases of epidemic proportions emerging in the population, there is an imminent need to closely monitor and direct health programmes in the country to meet the health needs of the population.
9.3.2 An efficient Health Information System is a prerequisite for effective administration of health services and achieving the stated goal of “Health for All”. Not only health information relating to aspects of health, such as, the existing health condition of the population, morbidity, availability of health facilities, availability of specialists, doctors and other paramedical personnel is essential for this, but demographic data, data on environment and socio-economic variables of the population are also very important for preparing a good health plan and implementing the same. These data are required for assessing the existing conditions and the resources for specification of goals and targets in terms of measurable output and for a continuous evaluation of achievements, when the plans are implemented. In brief, a good system of collecting health and other related statistics is absolutely necessary for: (a) preparing effective short and long term health plans, (b) effective administration and coordination of curative, preventive and other community health programmes, (c) studying the problems of health and disease which have implications for the administration of health services, and (d) evaluation, that is, an assessment of the effectiveness and efficiency of various health programmes.
9.3.3 In the context of data requirements for health planning, health-related data for any population should provide insights into following areas:
Demographic data: population by age and sex, rural/urban classification, geographical distribution, occupational classification, literacy, religion, marital status, migration, etc.;
Vital statistics: birth and death rates, infant mortality rates, life tables, general fertility rates, etc.;
Diseases: mortality rates by age and cause of death, morbidity data by age, sex, prevalence of communicable diseases, deliveries and statistics of anti-natal and post-natal care;
Facilities: hospitals, dispensaries, clinics, nursing homes, diagnostic centres, laboratories, equipments – X-ray and other diagnostic equipments, ambulances, beds, etc.;
Manpower: doctors, specialists and practitioners in allopathic, homeopathy and other Indian systems of medicine, nurses, pharmacists, lab technicians other supporting staff (their number, qualification, geographical distribution, availability per unit of population);
Finance: GNP, Government Revenue and Expenditure, allocation for health, budget estimates, sources of health finance, expenditure on health by voluntary agencies and other NGOs, private expenditure on health, etc.
9.3.4 During colonial rule, the development and growth of health care was based on the demands made by defence and civil administration, and consequently some data pertaining to public health and communicable diseases emerged. The Bhore Committee realised the deficiencies of databases on health and created a benchmark for a variety of health related information in its Report submitted in 1946. This Committee provided the first organised set of health care data for the country as a whole, prior to which records and reports of the public health department and the census were the only source of any health related information. The recommendations of this Committee for setting up sub-centres (SCs), primary health centres (PHCs), secondary and tertiary health centres on the basis of population size are still the pervasive pattern of health service delivery in the country.
9.3.5 Health is a State subject and vital and public Health Statistics are traditionally the responsibility of State Health Directorates. However, in a few States vital statistics have been the responsibility of State Directorates of Economics and Statistics. Presently, the Central Ministry of Health & Family Welfare (H&FW) consists of three Departments namely, Department of Health, Department of Family Welfare and Department of Indian System of Medicines & Homeopathy (ISM&H). The Directorate General of Health Services (DGHS) is the technical advisory wing of Ministry of Health & Family Welfare and is responsible for running the various national disease control/eradication programmes. At the national level, a small Bureau existed since 1937, which was organised in 1961 into the Central Bureau of Health Intelligence (CBHI) in the DGHS, Ministry of Health & Family Welfare, to coordinate and advise on the development of health information in the country. At the national level, it is the sole organisation dealing with collection, compilation, analysis and dissemination of health data for the country as a whole.
9.3.6 All national programmes are run by different sections of the DGHS, except the National AIDS Control Programme, which is directly run by the Central Health Department. As an offshoot of administrative procedures and implementation of various national health programmes, many data series flow into the various organisations/divisions of Directorate General of Health Services, Department of Health and these form the basis of the annual central health statistical publication Health Information of India brought out by CBHI. The central Programme Officers consolidate the programme-specific information flowing from States and UTs and furnish these to CBHI for publication. Data are also collected by CBHI directly from the Directorate of Health Services of all States and UTs, statutory councils such as, Medical, Dental, Nursing and Pharmacy Council, Office of Registrar General of India (RGI), and from other Central Departments and international organisations for publication. Data are presented at the State and UT level along with all-India figures. The combined issue for the years 1995 and 1996 is the latest issue. The combined issue for the years 1997 and 1998 is under print. These publications do not provide data below the State and UT level. Also the data published are not gender and age specific. Apart from the regular annual publication, Health Information of India, CBHI also brings out ad hoc publications. Health Map of India, 1998 is the latest among such publications of the CBHI and this depicts in maps, the district wise number of hospitals with bed strength and dispensaries, as also the number of specialised hospitals in various districts. The data are also presented in tabular formats side by side with the maps. The CBHI is also the nodal agency to implement the Health Management information System (HMIS) that was started to rectify the information deficiencies in the area of implementation of various health and family welfare programmes and by routine health service activities, as well as to provide linkages among them on a monthly basis. The HMIS however, did not function satisfactorily due to various reasons.
9.3.7 Apart from CBHI, the Rural Health Division of DGHS compiles and publishes Rural Health Statistics. This is a six-monthly bulletin, containing information on Government health infrastructure and manpower deployment in the rural areas. This publication also presents data at State and UT level. The National AIDS Control Organisation (NACO) under Department of Health collects data on cases and deaths due to AIDS/STD and publishes these in its Annual Update. This is not a statistical publication in the strict sense. CBHI also takes the data on important items from the Rural Health Division and NACO as well as from Department of Family Welfare and Department of ISM&H and publishes the same in Health Information of India.
9.3.8 The Department of Family Welfare is responsible for implementing programmes for population control and maternal and child health now renamed as Reproductive and Child Health. The Family Welfare programme is a Centrally- sponsored programme implemented by the respective States and UTs. The information flow starts from the peripheral level where the service delivery takes place. In the sub-centres, ANMs are responsible for the maintenance of records in respect of acceptance of family planning methods, services to pregnant women and immunisation for vaccine preventable diseases in respect of infants. The information flows to PHCs, and from PHCs to districts where it is consolidated for the district. From the district, the information in the prescribed form is expected to flow to the State and Centre through NICNET. Department of Family Welfare publishes Family Welfare Programme in India Year Book, annually. The latest issue relates to the year 1997-98.
9.3.9 The Department of ISM&H was set up in March 1995 with the primary task of developing and propagating Ayurveda, Unani, Sidha, Homeopathy, Yoga and Naturopathy. It collects information related to these areas and publishes these in: (a) Indian Systems of Medicine & Homeopathy in India (Annual), (b) Ayurvedic & Siddha Medical Colleges in India (Quinquennial), (c) Homeopathic Medical Colleges in India (Quinquennial) and Unani Medical Colleges in India (Quinquennial). In addition, Department of ISM&H also obtains information through surveys on “Usage and acceptability of ISM&H,” and “Demand assessment of Medicinal Plants”.
9.3.10 While in general, data on medical and health infrastructure (education and treatment) and manpower information are generated as a by-product of administrative and regulatory procedures, a source for morbidity data is the notification of Communicable Diseases, which is primarily meant for preventive control. Presently, data are also collected from selected surveillance centres in the country on the prevalence of HIV positive rate from random blood samples in the adult population. The hospital returns are analysed according to the list of diseases provided in the International Classification of Diseases (ICD) and a number of case-finding programmes for detection of cases on specified diseases like malaria, filaria, trachoma, goitre and leprosy are also available. The National Sample Survey also conducts demographic surveys, which have been providing information on some aspects of mortality and morbidity and household expenditure on health services and facilities. The licence registers for various categories of doctors, dentists, pharmacists, nurses, health visitors, etc. provide data about manpower and are consolidated by statutory councils such as the Medical Council of India, Dental Council of India, Nursing Council, etc. In the following paragraphs the deficiencies of various aspects of Health Statistics are discussed along with the recommendations on each of them.
I. Health Management Information System
9.3.11 The Health Management Information System (HMIS) was introduced in the country on a trial basis in 1982, as an integrated management information and evaluation system for health and family welfare programmes in four States namely, Gujarat, Haryana, Maharashtra and Rajasthan. The system was modified in 1990-91 on the basis of past experience, wherein; additional requirements of various programmes started by the Ministry of Health & Family Welfare were also taken into account. As extensive data are being collected by various agencies and compiled, there exist various problems, deficiencies and gaps. The system was not successful on account of non-reporting, under-reporting, variable coverage, delays in receipt of reports, data not being gender-specific and age specific, data not catering to the needs of the general public, etc. The major problems faced in the implementation of HMIS in the past were lack of hardware, software and trained personnel at the district and lower levels. The National Informatics Centre facilities were inadequate to meet the computing requirements of HMIS. Further, while the information for various programmes is collected separately by the peripheral worker and sent upwards from sub-centre, primary health centre and community health centre to the district and State levels, there is no coordination between the various health programmes implemented by the three Departments of Ministry of H&FW. Maintenance of patient care records is also very poor in most of the Government hospitals. The information from the private sector is not properly collected and included in the data generated by the official sources. Most of the States have not paid attention to implement the programme due to various reasons including lack of funds and trained manpower resources. As a result the HMIS has failed to achieve the objectives for which it was set up and has not functioned satisfactorily.
9.3.12 Due to poor implementation of HMIS by the States, the earlier system of collection of information by various programme authorities has continued to be in existence along with HMIS, which has created an undue burden on the peripheral workers as they have to fill up a number of proformae and maintain a number of records related to various programmes namely, malaria eradication, goitre, immunisation, MCH, family planning, blindness control, tuberculosis, AIDS and leprosy. A list of records and reports that are required to be maintained by the sub-centre functionaries (ANMs) is at Annexe 9.1.
Conclusions and Recommendations
9.3.13 The Commission observed that a computerised health information system at all treatment facilities is an essential prerequisite for establishing an effective Health Management Information System. The HMIS has a good potential to provide a comprehensive database on working of health programmes at the decentralised level upto the district. The HMIS if properly implemented would reduce delays in the information flow, provide qualitative information in a standardised form, avoid duplication and facilitate quick retrieval of information by all agencies concerned. In the Conference of Centre and State Statistical Organisations held in October 2000, most of the States agreed with the proposal for strengthening of the HMIS and suggested that the existing statistical cells in the Health Departments should be strengthened. However, while extending HMIS to private sector, the public sector record system also needs to be improved. The Commission therefore recommends that:
A comprehensive assessment of the Health Management Information System (HMIS) should be made by a small Committee quickly and HMIS be reintroduced in the country in a phased manner with necessary modifications. The combined HMIS format should be separated into programme-wise modules. While revising the programme modules, care should be taken to meet the data requirements of both the Central and State Governments. Flexibility should be given to the States and UTs to include additional items to meet their State specific data requirements.
Steps should be taken to rationalise and minimise the number of records and registers maintained by the peripheral health workers such as ANMs and public health inspectors to reduce their burden and to improve the quality of data. The minimum data set on which data from the grass root levels should be regularly collected along with their periodicity should be clearly identified.
There is a need for computerisation of the administrative records of all specialised hospitals and general-purpose hospitals and other treatment facilities both in the public and the private sectors. The International Classification of Diseases (ICD-10) Coding System for Medical Records should be adopted for generating morbidity and mortality data. There should be systematic training given to all medical personnel on the use of ICD.
The system needs to be revamped and expanded to include information on private sector health facilities by adopting an integrated approach for capturing data on both allopathic and Indian System of Medicine and Homeopathy.
Data relating to non-communicable diseases such as cancer, diabetes, mental disorders should also be collected through the HMIS.
A suitable mechanism to collect the data at the grass roots level and its upward transmission to the district, State and the National level should be evolved and for that methods of data collection, transmission, and processing must be modernised. As National Informatics Centre facilities are inadequate to meet the requirements of HMIS, adequate funds need to be provided for necessary hardware, software and connectivity and training of personnel.
The Central Bureau of Health Intelligence (CBHI), which is at present a part of Directorate General of Health Services (DGHS) should be separated and upgraded to a full-fledged Directorate of Health Statistics (DHS) directly under the Department of Health. An officer from the Indian Statistical Service at the Additional Secretary level should head this Directorate and act as the Statistical Adviser to the Department of Health. Also required posts of supporting officers should be created. The DHS should be the nodal agency in matters of health statistics and should advise the Department in all matters related to the collection of Health Statistics; coordinate with the National Statistical Office and agencies in the Central and State Governments, as well as international agencies in matters related to medical and health statistics.
The CBHI upgraded as DHS should be strengthened with adequate Electronic Data Processing (EDP) personnel and existing personnel should be trained in EDP operations, to enable the processing, tabulation and presentation of the large volume of data on health. Adequate funds out of the national health programmes should be earmarked for development and maintenance of information system as well as for verification of field level performance data through independent agencies.
In order to facilitate effective implementation of the HMIS in the States and UTs, the State Department of Health and Family Welfare in every State should have a Statistical Division headed by a senior level statistical officer. In the districts, a health statistics cell should be set up in the Office of Chief Medical Officer (CMO) to implement HMIS and to take care of all health and family welfare statistical activities of the district.
All States should bring out District Health Profile for each district containing information on medical and health facilities, personnel employed in health facilities, public health information, epidemic situation of the district, etc.
II. Data on Morbidity and Mortality at Disaggregated Levels
9.3.14 Data on morbidity and mortality form the core of any health planning strategy. The size and geographical distribution of occurrence of diseases and deaths by their causes for different age groups, sex, occupations and various other characteristics are of immense value to the public health planners, medical scientists, epidemiologists and researchers. Unfortunately, morbidity data or an epidemiological profile on which all health care planning should be based is primarily lacking. Morbidity and epidemiological studies on a nation-wide scale have never been done. The statistical data available through the statistical system of CBHI is deficient in respect of coverage, timeliness and adequacy. With regard to the data on mortality, the Registration of Births and Deaths Act, 1969, empowers the State Governments to introduce the system of Medical Certification of Cause of Death (MCCD) in specified areas in a phased manner, ultimately to cover the whole State. The scheme, which is functional in only 28 States and UTs is grossly deficient with regard to coverage, which is far from complete in almost all States. The latest available report pertains to the year 1995 and it indicates that only about 17 percent of the total registered deaths and 46 percent of the total registered urban deaths are medically certified. The Office of the Registrar General of India also conducts a survey on causes of deaths in the rural areas and provides some data on causes of deaths. However, the survey suffers from deficiencies such as, small sample size and reliance on laymen who report the cause of death. The system for building up a statistical database on morbidity and mortality along with causes of deaths further classified as per the International Classification of Diseases (ICD) is, therefore, in a poor shape. In the context of HIV/AIDS threat to the country, it is evident that mortality and morbidity patterns may show a rapid increase in the incidence of tuberculosis and other communicable diseases as a consequence of breakdown of the immune system because of HIV/AIDS. Indicators of infant, child and maternal morbidity and mortality computed from such data are, therefore, unreliable and do not reflect the true status of the child and maternal health. The National Family Health Survey (NFHS) conducted during 1992-93 and 1998-99 provided estimates of Maternal Mortality Rate (MMR) but only at the National level. With an increasing emphasis on decentralised planning the demand for data to derive mortality indicators at the State, district and lowest levels is increasing. However, the existing system does not have the capacity to meet these data requirements.
Conclusions and Recommendations
9.3.15 The present system of data collection through the Ministry of Health and Family Welfare, through MCCD or surveys conducted by RGI and NFHS on morbidity and mortality are unable to meet the data requirements of public health planners, medical scientists, epidemiologists and researchers. Further, there are hardly any estimates available at the district and below level, which is a serious handicap in planning the preventive action at these levels. The Commission strongly feels that the situation needs to be corrected by taking necessary interventions and recommends:
There should be periodic sample surveys of households on morbidity in the country, by trained investigators taking in to account the seasonal variations in diseases. These data should be analysed as quickly as possible and the morbidity patterns in the country should be published regularly. The National Statistical System should bring out regularly the morbidity and mortality patterns in the different age groups at least at the district/regional levels including for the diseases like T.B. and AIDS.
The morbidity and mortality surveys should be conducted in two stages. While at the first stage, the data could be collected on a fairly large sample; at the second stage, data from a sub-sample may be collected and verified by trained medical functionaries on certain specific aspects like causes of death, maternal mortality audit, etc.
As recommended by the Khusro Committee, the quality of data on infant, child mortality and maternal mortality can be greatly improved by conducting comprehensive sample surveys of pregnant women and by a follow up of these over one or more years after childbirth. Such surveys can be conducted on a small scale at local levels.
There should be a procedure for medical certification of the cause of death to be implemented at least on a sample basis throughout the country regularly, in order to have a better understanding of the causes or factors underlying deaths in the country. The death records should include symptom-based information on the possible cause of death.
The scheme of Medical Certification of Cause of Death (MCCD) envisaged under the Registration of Births and Deaths Act, 1969 should be strengthened. The State Governments should attach a high priority to the implementation of this scheme both in the rural and urban areas. There should be a system for prompt reporting of deaths due to certain diseases, like cholera, polio, malaria, diphtheria, etc. so that immediate preventive and curative measures can be taken.
The statistical system in all hospitals, nursing homes and other treatment facilities and dispensaries including those in the private sector should necessarily include certain basic information on each patient and this information in prescribed formats should flow to Health Statistical System within a fixed time frame. Computerisation of birth, morbidity and mortality records should be done in phases and should be coded with ICD-10 codes to facilitate processing.
III. Data on Expenditure and Social Consumption on Health
9.3.16 Another area of concern is the lack of readily available data on expenditure on health. Infrastructure and manpower form the bulk of non-plan expenditure of the State Governments in the Health Sector, though some inputs do come from the plan budget from the States and the Centre. There is at the moment no single source from where for any given year, all the information on non-plan and plan expenditure on health and family welfare incurred by the State Government; investment in different States made by the Ministry of Health and Family Welfare at the Centre; externally assisted projects in the Health Sector and investment by voluntary, private organisations in health sector can be compiled. The NSSO through its social consumption surveys provides information on consumption expenditure of households on health care but there is very little data on cost of care for different types of ailments and supporting medical services.
Conclusions and Recommendations
9.3.17 The Commission recognises the need for organising and streamlining the data gaps on expenditure on health and cost of medical treatment. These data are vital for planning cost effective provision of health care services. The Commission therefore recommends:
The Ministry of Health and Family Welfare in consultation with the concerned Central Ministries, Planning Commission, State Governments and other concerned agencies should develop a suitable mechanism for collection and dissemination of plan and non-plan expenditure on health services, infrastructure and manpower, investment and expenditure from private organisations, NGOs and externally assisted projects.
The data on availing health facilities and expenditure by households should continue to be captured more comprehensively from the NSSO’s surveys, which should be conducted on a quinquennial basis.
The cost of specialised treatment in respect of certain diseases such as kidney transplant, cardio-vascular surgery, etc. should be compiled institution-wise and published at least on an annual basis for the benefit of public. The NGOs and Medical Associations should be encouraged to publish and disseminate this information.
IV. Information from the Private Health Sector
9.3.18 Presently, Health Statistics are compiled in the Government Health Sector only as an offshoot of the administrative data collection. In the last few years, the private sector in a big way has been providing health facilities, not only in the urban areas but also in the rural areas. It is contributing significantly towards meeting the basic health care needs and in providing other specialised medication and diagnostic services. However, there is no systematic collection of information regarding these private health establishments, as these are not required to be registered. Therefore, there is complete lack of information on even the number of these health facilities in a given area. Some information may be available on the financial aspects of bigger establishments, which are registered as companies under the Companies Act in the form of their Annual Accounts. These data are important from the National Accounts point of view, but does not serve any purpose of health administrators who are interested in several other factors related to health. Although there are a few regulatory Acts covering registration of medical personnel (e.g. Indian Medical Council Act, 1956; Indian Dental Council Act, 1948; Pharmacy Act, 1948; Indian Nursing Council Act, 1947), no law or regulation exists for registration of medical and health facilities such as nursing homes, diagnostic centres, laboratories, and hence no information exists for such health facilities. Some States such as Maharashtra, Sikkim, Manipur, Tamil Nadu, Delhi, etc. already have such an Act in force.
Conclusions and Recommendations
9.3.19 With the increasing participation of the private sector in providing health care facilities, it is not only important to regulate in some way the activities of these health facilities for ensuring quality of services provided to the public, as also for other purposes such as, controlling the waste disposal and to deal with pollution related aspects. For health policy-makers, such regulation is important to capture data to meet their requirements. The data on the income and expenditure is important for the national accountants to estimate the contribution of this sector to the national income. The Commission therefore recommends:
The Centre should formulate a model Act for registering and regulating health facilities in the private sector. All the States should bring out State level Acts for this purpose on the lines of the model Act. A system of periodical filing of statistical returns with the statutory body should be established. The law should have provision for penalty and even deregistration for failing to file such information with the statutory authority.
The statistical system in all hospitals and dispensaries should necessarily include certain basic information on ailments of inpatients and outpatients, health personnel, health infrastructure such as number of beds, income and expenditure, etc. and such information on a regular basis should be furnished to the National Statistical System, so as to become a part of an improved database on health.
V. Information for Manpower Planning in the Health Sector
9.3.20 The statistical information required for health planning includes data on number of medical, paramedical and other health personnel in the public sector as well as private and voluntary sector institutions that are providing health care to the population; individual medical practitioners and paramedical staff to work out the doctor-population ratio, doctor-nurse ratio, bed-population ratio, etc., and to assess their availability by geographic distribution and by size of population. Data is also required on changing requirements for the health manpower based on the changing health care needs of the population at the district, State and National levels. Even though Medical Council of India, Dental Council of India, Nursing Council are required to supply information to CBHI on registration of allopathic doctors, dentists and nurses, the information is not updated regularly for those who have retired or died or left the country. The quality of data is in general, unsatisfactory.
Conclusions and Recommendations
9.3.21 The information on manpower in the Health Sector is vital for planning and working out important indicators such as ratio of doctors, nurses, etc to the size of population in a given geographical area. The Commission recommends that:
The statistical system in the Medical Councils concerned with Allopathic, Homeopathic, Dentistry, Indian System of Medicine and paramedical personnel should be strengthened to provide updated data on number of medical and paramedical personnel in both the rural and urban areas at least upto the district level.
The information on all medical practitioners, dentists, paramedical personnel, pharmacists and nurses of various systems should be compiled by the Councils and be made available at the district level and should be updated every two years. They should also be made available on Internet.
VI. Methodology for Couple Protection Rate (CPR)
9.3.22 Couples currently protected under various methods of Family Welfare Programme, include those who accepted the programme, leaving out those who have dropped out because of mortality or widowhood and attrition due to ageing or discontinuation of method in case of IUD and conventional contraceptives. The estimation of CPR is based on the methodology suggested in 1970s and there have been suggestions to revise the methodology taking into account the contemporary requirements. The Department of Family Welfare constituted a Committee in 1994 to look into this aspect and it is understood that the Committee has submitted its Report to the Government. The Commission therefore recommends:
The data on Couple Protection Rate (CPR) provided by the Department of Family Welfare should be critically looked into for the relation it bears to actual contraceptive prevalence rate. Suitable modifications should be made to re-define the data needs on contraceptive acceptance, use of family planning methods and computation of the couple protection rate from official statistics.
The methodology for estimating the Couple Protection Rate (CPR) should be revised, if necessary in view of the recommendations made by the Committee set up by the Department of Family Welfare for this purpose.
VII. National Family Health Surveys
9.3.23 The two National Family Health Surveys (NFHS) conducted in 1992-93 and 1998-99 have collected important information on the health, status of the population, family planning, fertility and mortality as well as growth and development of children, levels of anaemia of women and children and related parameters at the State and National levels which were not available earlier. In the second round, it has also collected data on the prevalence and perception of domestic violence. These surveys have been conducted by the International Institute for Population Sciences, Mumbai with almost total assistance from the international donor agencies. The cost of these surveys is quite high compared to national surveys conducted by NSSO. However, given the importance of this survey, it is recommended that
National Family Health Surveys similar to those conducted in 1992-93 and 1998-99 should be conducted periodically using national resources, if funds are not available from any other agency.
VIII. Use of Information Technology in Improving Health Statistics
9.3.24 There is a considerable time lag in the availability of different types of Health Statistics. Primary health care being a State subject, the Directorates of Health Services of States and UTs are the nodal points for collection and publication of primary health data, collected from the grass roots level through multi-purpose workers. As extensive data are being collected from various agencies and compiled, delays are inherent, compounded by lack of priority and interest given to statistical work. Other related aspects are lack of statistically trained manpower for effective supervision and scrutiny of data collected by the primary worker. In many States as well as at the Central level, the Health Statistics Systems are not developed and computerised. Data flows from district to State and finally to Centre are not transmitted through a fast communication network and are dependent on traditional postal methods resulting in delays and also problems of quality. The Commission recommends that:
Steps should be taken for the adoption of Information Technology and introduction of a unified system of computerisation and networking for data transmission from one level to another, to reduce delays in transmission and compilation of Health Statistics, and to improve the data quality, to derive various indicators and to retrieve information promptly on health related issues as and when needed.
Civil Registration System (CRS)
9.3.25 The Civil Registration System of a country envisages recording each and every incidence of vital event for legal purposes and in the process captures a lot of information on various characteristics of these events, which help in the compilation of a continuous series of vital events. Complete, timely and accurate registration of births and deaths is very crucial for the understanding of population dynamics at the local level and planning of effective health and development programmes. The extent of completeness and accuracy of birth and death registration is by itself an indicator of the modernisation of society as vital statistics belong to the Core Statistics of any National Statistical System. In India, civil registration was first introduced in the last century mainly as an aid to public health administration for locating and identifying diseases of public health importance and to undertake remedial measures to control mortality. However, registration was kept voluntary and different provinces had different legislations and there was no standardisation of concepts, definitions and classifications. Various Commissions and Committees have reviewed the civil registration based vital statistics system in the past. The enactment of the ‘Registration of Births and Deaths (RBD) Act, 1969’ replacing all diverse laws that existed on the subject, and the Model Rules framed under the Act introduced a uniform piece of legislation to overcome the problems of multiplicity of Acts and Rules that existed in the country. Thus, the Act aimed to have a uniform system of registration and data collection on vital statistics. The Act provides for compulsory registration of births and deaths in the country. However, registration of marriages and divorces is not compulsory in India.
9.3.26 The RBD Act has provided for a hierarchical set-up for the registration machinery in the country, headed by the Registrar General of India at the Centre, The Chief Registrar of Births and Deaths is the chief executive authority in the State for implementing the provisions of the Act. There are District Registrars in the districts and Registrars and Sub-registrars for registering births and deaths occurring in the area allotted to them within a district. The States with the approval of the Central Government have made Rules in accordance with the Model Rules to implement various provisions of the Registration of Births and Deaths Act.
9.3.27 It is estimated that 26 million births and 9 million deaths occur in India every year and based upon the reports received, only 53 percent of births and 48 percent of deaths are registered. About 10 million births, which are about 25 percent of the unregistered births in the world and about 4 million deaths, are not registered. The poor registration in the rural areas of the country is the main reason for incomplete registration. On the basis of births registered in rural and urban areas, assuming that these births have taken place to the population living in these areas, the estimated birth rate works out to 12 and 24 per thousand respectively against 28 and 20 per thousand estimated from Sample Registration System during 1995. Even if it is taken that a sizable proportion, say 35-40 per cent of the births registered in the urban areas come from the population living in the rural areas, the birth rate of the rural areas could be estimated at around 14 to 15 per thousand, which shows that the level of registration in the rural areas may be around only 50 per cent. Further, the levels of registration of births and deaths vary widely across the States, as shown in Annexe 9.2. Thus, the Civil Registration System suffers from incomplete coverage and the problem is more acute in a few States, which account for a big chunk of this incomplete coverage. Given the complete coverage, the CRS has the potential to provide estimates of vital rates such as birth rate, death rate, infant mortality rate and other related fertility and mortality indicators even at the district and below levels and will be of immense importance for micro level planning for development. However, due to incomplete coverage of the system, these estimates are made available at the State level only through the Sample Registration Scheme (SRS). However, even the estimates of infant mortality rate for small States and UTs are not reliable due to the small sample size.
9.3.28 There are more than 200,000 reporting units in the country and more than 100,000 local registrars doing the actual work of registration. Monitoring the receipt of statistical returns from each and every registration unit on a monthly basis is a challenging task. Other requirements are of training, supervision and maintenance of a timely supply of forms and registers in the registration units.
9.3.29 A combination of administrative factors is responsible for the poor registration levels of vital events. Except for a few States and UTs, generally multiple agencies are involved in the registration work (see Annexe 9.3) at the sub-national level. This poses immense problems of coordination, monitoring and supervision, which directly affect the quality and timeliness of data. Though high -level inter-departmental committees exist, they have remained ineffective in improving the situation in most of the States. Further, the registration functionaries at all levels do the work of registration in addition to their other normal duties in an honorary capacity generally, without any incentive. This is why the work of registration, preparation and submission of statistical returns do not get due attention and priority. The quality of data becomes a major casualty. The number of Registration centres has also been a contentious issue. If this number is too small there are problems of accessibility. On the other hand, a large number of registration centres pose huge problems of control, management and supervision. Lack of adequate budget for supplying material resources such as forms and registers, for meeting training and supervisory requirements and publicity efforts put a constraint on the system to perform better. With regard to the registration of marriages, though legislations exist in some States, however, there is no uniform legislative enactment in the country. Some of the existing enactments are applicable to specific religious groups. There is also no provision for registration of divorces.
9.3.30 Even in States that have achieved high levels of registration, there is a considerable delay in reporting of statistics from the local registrars, eventually delaying the compilation of vital statistics at the State and National levels. A lot of paper work required and pending at the level of Registrar is one of the major reasons for the delay in submission of returns. Different States have different arrangements for processing the data on civil registration, depending on the number of registration centres, availability of manpower in offices where tabulation is done and the level of computerisation at the State headquarters. Varying lengths of time taken for intermediate tabulation at the district and town/municipality levels seriously affect the tabulation work at the State level resulting in the failure of States to meet the time limit prescribed under the law for publication of statistical reports.
9.3.31 The other factors that lead to incomplete registrations are a general lack of awareness in the public about the statutory requirements and procedures of registration, lack of demand of birth and death certificates in rural areas, acceptance of alternate documents as proof of death, and lack of perception of any benefits of registration by the people. Further, the registration centres are not always easily visible. Around 75 percent of births and 80 percent of deaths are domiciliary in nature and the statutory reporting of the events lies with the household.
Conclusions and Recommendations
9.3.32 The Civil Registration System (CRS), which is capable of providing vital rates not only at the district but also lower level, is deficient in most of the States and UTs. The justification for improvement in the system of civil registration and vital statistics would usually be based on a demonstration of the potential of such a system to create individual records that are useful for legal and administrative purposes and also to aggregate them into usable statistics. The CRS in the country has so far not served the needs for which it was set up and therefore; it attracts low priority and attention not only by the Government but also by also potential users. The Commission observes that incomplete registrations and delays in the upward movement of the registration data have been major problems for timely processing and publication of the results of the Civil Registration System and this has undermined the its utility. At present it is a passive system, in which most people do not realise the importance of reporting births and deaths. Where ANMs and other village level workers have been given the responsibility of reporting births and deaths to the Registrar there has been a positive impact. In spite of demands for publication of the absolute number of births, deaths, infant deaths, etc., such figures are not available. There is growing need for district level vital statistics, which is a major lacuna in the way of decentralised planning. Recently, released provisional results of the Census 2001 have revealed that the population has grown at a faster rate than estimated and the sex ratio in the age group 0-6 years has declined considerably during the last decade form 945 to 927. Had the Civil Registration System in the country been efficient in covering all births and deaths and bringing out data in time, it would have been possible to introduce necessary preventive measures in time. The results of Census 2001, once again stress the need for an efficient Civil Registration System. The Commission also recognises the goal of attaining of complete registration of vital events namely, births, deaths, marriages and pregnancy as one of the 14 socio-demographic goals to be attained by the year 2010 in the recently announced National Population Policy, 2000, and therefore recommends:
There should be a more pro-active Civil Registration System in place of the existing passive system. In rural areas, panchayats, local bodies and other basic and primary workers apart from Auxiliary Nurses, Midwives, Village Watchmen should play an active role in informing the Registrar about the occurrence of vital events. They should collect birth and death information from households and deliver the same to the Registrar. All States should implement this as a part of strategy to improve the registration. This can be achieved by giving the local level workers the responsibility for informing and collection of reports of events and getting them registered.
Within a State, as far as possible, only one department of the Government should be responsible upto the district level for implementing the provisions of the RBD Act. Where multiple departments are involved, inter-departmental coordination committees should ensure effective and periodic reviews to propose measures for improving registration levels and provision of registration services by drawing up a plan of action. This requires tight monitoring and supervision of the registration work at the field level.
Recognising the increasing role of local self-governance in the light of the 73rd and 74th Constitutional Amendments and considering the fact that quite a few States in the country have already taken initiative in this direction, the panchayats in the rural areas and Municipalities in the urban areas should gradually be given the responsibility for registration of births, deaths and marriages.
Sufficient resources should be provided to the agencies implementing the Registration of Births and Deaths (RBD) Act. The Planning Commission should provide funding to the States for this purpose. Further, to improve the availability of required forms and registers used for registration of vital events, the Central Government should bear the expenditure on this account.
Regular training programmes should be organised by the States for Registration officials at all levels. The ‘Registrar’s Manual for Registration of Births and Deaths’ being prepared by RGI should be made available to all concerned, and training programmes should be conducted to impart training to all Registrars in the use of the manual.
The revamped system of registration of births and deaths in the country introduced by Registrar General of India, mainly with a view to strengthen the statistical functions of the CRS and to reduce paper work at the level of the local Registrar, by facilitating computerised data entry, easy retrieval of records and reducing storage requirements of records, should be vigorously implemented in all the States. There should be special emphasis on the monitoring and supervision of the system particularly for poorly performing States in order to enhance their performance.
Production of birth and death certificates should be encouraged for various purposes, as it will help in improving the overall registration of vital events. For example, the production of birth certificates should be made mandatory for entering the name of new-born child in the ration card, school admission, etc., and death certificates for settling insurance claims and for inheritance of property by legal heirs, in case it is not so already in any State and UT.
Considering the stated goal in the National Population Policy of 100 per cent registration of marriages by 2010, sustained efforts should be made to achieve this goal through the Civil Registration System by suitably amending the RBD Act for registration of all marriages and divorces.
Public campaigns should be launched to create awareness among the general public about the need and importance of registration of births and deaths. Also steps should be taken to improve customer services by making registration centres more visible, prompt issue of birth and death certificates, simplifying the procedure, making registration in big hospitals more efficient and proper preservation and maintenance of records of vital events.
Acknowledging the fact that an efficient Civil Registration System is the lasting solution to produce a regular series of vital rates e.g., fertility, mortality, etc. specific for age, sex, and educational level upto the district and even lower levels, the ultimate goal should be to put in place the Civil Registration System in the next 10 years and to use the Sample Registration System (SRS) as a source of data for longitudinal study of the social dynamics of the country and as a means of validating the CRS data.
Recourse to Information Technology (IT) should be taken for establishment of an effective system of civil registration that would provide prompt service to the public and help in quick retrieval of information for both administrative requirements and statistical purposes. As the costs of hardware and network communications will come down in the coming years, decentralised data entry and data transmission at the Registration level should be the goal to be achieved within a few years. Sustained efforts should be made for adoption of IT in modernising the CRS. The computers provided by the Department of Family Welfare, Government of India may be utilised for this purpose as well.