Table 2

Design, sampling and human resources for VA

CountryDesign and samplingHuman resources
Integrating processesSamplingCommunity operational considerationsDeath notificationVA interpretationInterviewerTraining providedIncentives
ChinaChina will need BPM if they plan to integrate VA into current death surveillance systemPilot sites covered 27 districts from 12 provinces, with different geographical and socioeconomic index areas.
Pilot sites were chosen using these criteria:
  • Sites with a crude death rate similar to that of the province from which they were chosen.

  • Sites with a high proportion of deaths occurring at home.

A variety of community considerations needed to be accommodated:
  • Different culture/customs of local residents/ethnicity.

  • Dialect/language/accent used in the remote villages.

  • Necessary to contact community/village leaders in advance of implementation.

Each site had different issues related to death notification—solutions that needed to be tailored to specific contexts.3 rounds of pilot VA study were analysed and interpreted by national-level senior death surveillance staff.District-level CDC staff or community/village doctors5 days’ training for first round by D4H team (in English); 2 days training for second and third rounds by D4H and China CDC together (in Mandarin)Small incentives in some locations of the pilot sites (required in some districts).
MyanmarBPM outlined the existing system of midwives currently responsible for registering deaths which was also used for VA.
  • Pilot sample was 14 townships from three states/regions.

  • Roll-out was nationwide sample of deaths in 42 townships (at least 2 townships from each state/region) representing 15% of the national population.

  • Some parallel procedures were necessary to incorporate both death registration (form 201) and VA.

  • Midwives sometimes used their own mobile device to record VA interviews rather than retrieve tablet from a rural health unit far from the village.

Nominated people in the village contacted the midwife in the case of a death in contrast with previous ad hoc system.
  • Six monthly and annual analysis of VA by a team from the CSO and HMIS. Individual cause of death data from VA did not go into the CRVS online system but were analysed separately.

  • Dissemination with all agencies and levels of government and discussion of results and implications with mortality TWG.

Basic health staff (midwives and Public Health Supervisors 2).5-day training using master training model. D4H team train master trainers who then train VA interviewers. Final day is field practice.No incentives—part of routine work and extension of their existing task of registering deaths.
PNGBPM identified key weaknesses, particularly with death notification, and enabled stakeholders to identify the main requirements for a functional system, such as the involvement of health workers in notification as well as VA activities.
  • Purposive sample made to represent PNG’s epidemiological, geographical and cultural diversity.

  • Sites were selected on whether there was sufficient local government support and experience with the electronic National Health Information System.

A key consideration is the remoteness of many communities. Enabling community health workers to take the Android tablet back to their communities from the health centre when they visit on a monthly basis was successfully trialled for increasing completeness of death notification and VA.District mortality surveillance sites are trialling strategies and personnel to facilitate death notification, locally identified reporting agents, and death notification and VA conducted through the health system.Cause of death from VA is not recorded by the Civil and Identity Registry. VA data are analysed by the National Department of Health on an ad hoc basis. Data are critically appraised by the National Burden of Disease Technical Advisory Committee.Health extension officers, nurses and community health workers3-day trainingIncentives for completion of death notifications and VAs, as well as additional direct logistics funding in short term prior to these becoming recognised routine activities
PhilippinesBPM, site visits and workshops with municipal health officers were required in the first 6 months. These activities helped identify the main requirements to improve cause of community deaths.
  • The larger and remote municipalities were samples for the pretest

  • Three language groups were included for the pilot study.

Understanding the workflow at the Municipal Health Office and integrating SmartVA into the routine was important for uptake of VA.N/ANo additional integration is needed as VA is used to certify deaths, the certificates are sent to the Philippine Statistical Authority and processed along with the hospital based death certificates.Municipal health officer (doctor)3-day training on VA and medical certification of cause of deathNo incentives. There is a national policy mandating the use of VA.
Solomon IslandsIntegration required BPM, collaboration with DHIS-2 technical staff, extensive provincial visits and consultation at all levels of health system.Pilot sites chosen for convenience with some representative diversity, then scale-up to national coverage.Regular supportive supervision, along with community death notification mechanisms and a USB-memory stick alternative to internet upload were all trialled to overcome barriers of remoteness and lack of internet.Piloted use of religious leaders, cemetery authorities and primary health workers as notifying agents.Six monthly analysis by National Health Information System team who share results with provincial health teams and National Mortality Technical Working GroupNurses (hospital emergency departments and subprovincial facilities)5-day trainingNo incentives, part of routine work
  • BPM, business process mapping; CDC, Centers for Disease Control; CRVS, civil registration and vital statistics strengthening; CSO, Central Statistical Organisation; D4H, Bloomberg Philanthropies Data for Health Initiative; DHIS-2, District Health Information System (IT platform for health data); HMIS, Health Management Information System; N/A, not applicable; TWG, Technical Working Group; VA, verbal autopsy.