The World Health Organization’s (WHO) latest estimates of the pandemic in India show that the health crisis has claimed nearly 5 million lives in the country in the past two years. The WHO estimate of the pandemic toll includes both the direct and indirect impacts of COVID. This includes deaths of non-Covid patients who died due to lack of timely care, for example, when hospitals were full of COVID patients and had to turn away others.
Official spokesmen for the government have objected to the WHO’s estimates, and even questioned the intent of its team. Citing the recently released Civil Registration System (CRS) report for 2020, the Center has claimed that the number of additional deaths in 2020 was actually very low.
These objections make no sense. The CRS report suggests 0.8 million more deaths in 2020 than the average for the previous two years. WHO figures also suggest more similar deaths for 2020. WHO’s final numbers for the period 2020-2021 are much higher as WHO estimates that there will be around 4 million additional deaths in 2021. The CRS report for 2021 is yet to be published and hence a direct comparison is impossible. But provisional CRS figures for several states accessed by journalists (and what the WHO used in its estimates) suggest that the summer of 2021 (when our second wave of COVID-19 peaked) saw a much higher death toll than 2020. View registration.
The final Indian official tally based on the CRS is likely to be closer to the WHO estimates, as it will include the impact of a second wave. A convergence between the Centre’s death toll and WHO figures, once the 2021 numbers are taken into account, should surprise no one, as they both rely on the CRS.
This raises the question whether the CRS tally is an accurate measure of deaths in India. The answer, unfortunately, is a big ‘no’. CRS drastically reduces deaths in some of India’s most populous states, such as Bihar and Uttar Pradesh. This includes the deaths of children and women as well.
The Registrar General of India (RGI), who runs the CRS, itself does not consider the CRS to be the most authentic barometer of mortality rates across the country. It uses the Sample Registration System (SRS), a random large-scale survey, to estimate the number of deaths. The ratio of registered deaths (recorded by CRS) to estimated deaths (from SRS) is defined as the “level of registration”, which indicates the coverage of the CRS system.
The system worked fine as long as the SRS was able to measure deaths accurately. But the dark secret of India’s official death-recording system is that SRS data quality has deteriorated over time. Independent studies suggest that SRS is reducing the death count especially in better developed states. A 2010 study by Prashant Mohapatra of the Hyderabad-based Institute of Health Systems suggested that states such as Andhra Pradesh and Maharashtra have lower SRS numbers than states such as Odisha and Uttar Pradesh. A 2020 study by Chalapathi Rao of the Australian National University showed that SRS reduces adult male deaths in most states.
Expansion in CRS over the past decade has exposed fatal flaws in SRS data. In states such as Haryana, Karnataka and Tamil Nadu, the CRS now reports more deaths than the SRS, which means the level of registration is technically more than 100%. Yet, for children and women in most states, CRS still reports fewer deaths than SRS.
So we have a uniquely broken death-recording device in the country. The CRS fails to capture the mortality rate among the poor, women and children. The SRS fails to capture deaths among non-poor and adult males.
Given that both the systems are deeply flawed, it is impossible to ascertain the exact level of registration from the CRS and SRS numbers. A more reliable measure comes from the National Family Health Survey (NFHS), a large-scale household survey that is nationally representative. The latest data for 2019-21 shows that in the three years prior to the survey, just 71 per cent of the households had registered a death in their family. The figure was even lower at 52% for the poorest wealth quintile. Among the major states, Bihar (36%), Jharkhand (40%), and Uttar Pradesh (47%) saw the lowest level of registration. Goa was the only state to have reported full death registration.
Instead of waging a futile battle with WHO technocrats, Indian policy makers need to find ways to reform our death-recording system. CRS coverage has expanded over time, but it is much less than universal coverage. Therefore estimating the toll of the pandemic based on CRS or SRS data would miss many deaths in many parts of the country. Such estimates can only provide a lower bound for the actual toll of the pandemic.
It is time to redouble efforts to improve CRS and SRS systems, as both of them are critical to understanding mortality and health patterns across the country. The database on ’cause of death’ also remains poor. This also needs immediate attention.
Instead of harassing global experts to do their job, Indian policy makers should engage with them to help improve our vital statistics. Until we are able to get accurate patterns of deaths and diseases in the country, we will always struggle to improve health outcomes. And until such data is available on a real-time basis, we will be prepared for the next health shock. We should not need any inducement from multilateral agencies to publish regular health data in a timely manner.
Prameet Bhattacharya is a Chennai based journalist. His Twitter handle is pramit_b. is