1. The Global Summit on CRVS
Civil Registration System,
Sample Registration System
&
Annual Health Survey :
Issues and Policy Uses
DR. R. C. SETHI
FORMER ADDITIONAL REGISTRAR GENERAL, INDIA
Office of the Registrar General, India
18-19th
April 2013

2. OVERVIEW
Civil Registration System- Status, Challenges
and Initiatives
Sample Registration System, 2011- Key
Results
Annual Health Survey, 2009-2011- Highlights
of the baseline survey

3. Civil Registration System
• Comprehensive and complete CRS has multi-faceted
implications on socio-economic development of a country.
• A complete & up to date CRS can provide:
 Reliable Statistics on fertility & mortality at all level of
aggregations
 Almost on a real time basis which is not possible from any
sample survey.
 Key for evidence based planning and has no parallels
• The levels of registration reflects the quality of
governance.

4. Civil Registration System (CRS)- Scenario
• Registration of Births and Deaths in India is mandatory
with the enactment of Registration of Births and Death
Act (RBD Act), 1969.
• Registration of Births and Deaths falls under the
Concurrent list of the Constitution.
• Registrar General, India unifies and coordinates the
activities of the States.
• States are responsible for implementation of RBD Act.
• National Population Policy mandates cent percent
registration.

5. • LOR (Birth) – India: 62.5% to 81.3 % ( + 18.8 %)
• LOR (Death)– India 55.0% to 66.9% ( + 11.9%)
• 13 States/UTs have achieved 100% registration
of births.
• 6 States/UTs have achieved 100% registration of
deaths.
• Some of the major States remains the main
concern.
Registration Scenario in India during last 5 years

6. Level of Registration of Births and Deaths, 2000-2009
 Still every 5th
birth & every 3rd
death goes un-registered.

7. Issues
 Utility of birth and death certificate- Enhancing the utility
and awareness among the general public, a cause of
concern.
 States/UTs are functioning at different level of efficiency-
reflects the governance.
 Flow of registered vital events- a bottleneck in monitoring.
 Under reporting of domiciliary infant deaths & still births
and misclassification of maternal deaths in better
performing States- how to estimate IMR & MMR?
 Utility of data gets diminished on account of delayed
reporting by the States.

8. Initiatives to re-vitalise the system
 To enhance the utility, MOHFW has linked the delivery of
services with registration e.g. cash incentive under JSY etc.
 Provision for incentive to the States and to grass-root
workers Anganwadi/ASHA for registration and delivery.
 Ministry of Health has made registration as one of the focus
areas under National Rural Health Mission (NRHM)/ NHM.
 To cover all institutional events, a database of Medical
Institutions is being prepared.
 Provisions of the Act are being simplified for better
implementation.
 Linking CRS at sub-district level to update NPR.
 Collaboration with various partners for further
strengthening of the system.

9.  Introduced in early 1970s to provide cause-specific
mortality profile.
 Restricted to urban areas, that too few selected
hospitals.
 At various stages of implementation across different
States.
 Coding is as per ICD-10.
 Covers about 19% of the total registered deaths only.
 Garbage codes(R00-R99) are to the tune of 14%.
Medical Certification of Causes of Death (MCCD)

10. Time Series on Medically Certified Deaths vis-a-vis Total Registered Deaths Reported
for the Period 1986-2007
ORGI has expanded the scope under MCCD to all Institutions
including individual practitioners and the coverage , extended
to rural areas as well.

11. Sample Registration System
Genesis
Initiated in 1969-70 for want of complete registration from CRS.
Objectives
 Provide reliable annual estimates of birth, death and infant mortality rates
at the State and National levels separately for rural and urban areas.
 Also provides Child Mortality Rate (CMR), Total Fertility Rate (TFR), Sex
Ratio at Birth and 0-4 age, Institutional deliveries, Medical Attention before
death, etc.
 Under 5 mortality rate also generated from 2008 annually.
Features
•One of the largest demographic household sample survey in the world
 Sample size determination based on IMR
 Permissible level of RSE: 10% (bigger states)
 1.3 million households and about 7 million population
 Only panel survey with dual recording
 Panel revised once in 10 years based on the latest available Census frame

12. • Of the 8 MDGs, IMR, U5MR and MMR are generated by SRS.
Goal
No.
Goals Indicators
Targets
by 2015
4
Reduce infant mortality Infant Mortality Rate (IMR) 28
Reduce child mortality Under 5 Mortality Rate (U5MR) 42
5 Improve maternal health Maternal Mortality Ratio (MMR) 109
MILLENNIUM DEVELOPMENT GOALS(MDG)

13. • MMRatio measures number of women aged 15-49 years dying
due to maternal causes per 1,00,000 live births.
• Decline in MMR estimates in 2007-09 over 2004-06:
 At the country level, it has declined to 212 from 254 (a fall of about
17%)
 It varies between 81 in the State of Kerala to 390 in Assam ( a variability
of 5 times).
• MDG target of 109 have been achieved by 3 States viz. Kerala,
Tamil Nadu & Maharashtra.
• 4 States viz. Andhra Pradesh, West Bengal, Gujarat and
Haryana are in closer proximity to achieving the MDG target.
MMR ESTIMATES 2007-09

14. TREND IN MMRatio- India
(2004-06)
2009
2007-09 SRS
212
56 000
(2007-09)

15. Region MMR Life time
risk
% share of
female Popln.
% to total
maternal deaths
EAG states 308 1.1% 48.0 61.6
Southern
states
127 0.3% 21.0 11.4
Other states 149 0.4% 31.0 27.0
India 212 0.6% 100 100
LEVELS OF MMRATIO BY REGIONS, 2007-09
 ½ of the female population of EAG States contributes about
2/3rd
of Maternal Deaths.

16. Total Fertility Rate (TFR) BY RESIDENCE, 1990-
2011
 TFR for the country declined by 1.4 points (down by
more than a child), rural TFR also by 1.4 points and
urban TFR by 0.9 point over last 21 years.

17. ANNUAL HEALTH SURVEY-
DISTRICT LEVEL MONITORING

18. “To yield a comprehensive,
representative and reliable dataset on
core vital indicators including
composite ones like IMR, MMR and
TFR along with their co-variates
(process and outcome indicators) at
the district level and map changes
therein on an annual basis.”
OBJECTIVE OF AHS

19. Coverage : Annual Health Survey
Odisha
Chhattisgarh
JharkhandMadhya Pradesh
Bihar
AssamRajasthan
Uttar Pradesh
Uttarakhand

20. o
AHS States constitute:
• 48 percent of country’s Population
• 59 percent of Births
• 70 percent of Infant Deaths
• 75 percent of Under 5 Deaths
• 62 percent of Maternal Deaths
o
Enable direct monitoring of UN Millennium
Development Goals on Child Mortality and Maternal
Health at the district(s) level.
o
Help in identifying high focus districts meriting
special attention in view of stark inter-district
variations in these States.
WHY AHS ?

21. • Panel Survey on the pattern of SRS.
• Coverage- All the 284 districts of 8 EAG States and Assam.
• Sample Size- IMR as the decisive indicator with 10%RSE.
• Sample Units- 20,694 statistically selected sample unit
(Census Enumeration Blocks in urban areas and Villages or a
part thereof in rural areas).
• Sample Population- About 20.1 million.
• Sample Households - 4.1 million households.
• Sample Units per district- 73.
• Sample Population per district - About 71 thousand.
• Sample households per district - About 14.5 thousand.
The Largest Sample Survey in the World
KEY FEATURES

22. •In all, 161 indicators are available from AHS baseline:
Fertility- 13  Sex Ratio- 3
Marriage- 5  Mortality- 7
Mother & Child Care- 63
Ante Natal Care: 11  Delivery Care: 8
Post Natal Care: 5  Janani Suraksha Yojana (JSY): 3
Immunization: 8  Vitamin A & Iron Supplements: 2
Birth Weight: 2  Childhood Disease: 6
Birth Registration: 2  Breastfeeding & Supplementation: 12
Awareness in Mothers: 4
Abortion- 6  Family Planning Practices- 15
Disability- 1  Morbidity- 19
Personal Habits:adults-4  Housing & HH Characteristics- 13
Others- 12
INDICATORS UNDER AHS

23. Orissa
Chhattisgarh
Jharkhand
Madhya Pradesh
Bihar
AssamRajasthan
Uttar Pradesh
Uttarakhand
Infant Mortality Rate
Top 100 Districts in AHS States

24. Clinical, Anthropometric & Bio-Chemical Component
• CAB component of the AHS would provide
district level data on the prevalence of the
following in a selected sub-samples of
households across all the AHS districts.
under and over nutrition,
anaemia,
hypertension,
fasting glucose levels, and
household availability of iodised salt

25. POLICY IMPLICATIONS
 Policy needs particularly in respect of reliable and timely data
have undergone a paradigm shift since last 50 years.
 State level estimates are used for both central as well as state
level planning. Also for pop. Proj., life tables, IMR, MMR, HDI
etc.
 SRS was therefore designed as a stop-gap arrangement to
bridge the data gap at national and state levels in view of an
deficient CRS.
 Non availability of district level estimates thwarted the need
for sub-state level planning despite the recognition of the
facts that state averages mask the reality.

26.  AHS conclusively proved the above hypothesis and stressed
the importance of identifying the hotspots (districts
requiring special attention).
 Availability of such a rich and comprehensive dataset would
help in accessing the impact of various health interventions
including those under NRHM/ NHM – JSY, SRB.
 Estimates of IMR at district level and MMR for a group of
districts would enable tracking of MDGs at below state level.
 District level estimates would provide requisite inputs for
better planning of health programmes and pave the way for
evidence based intervention strategies.
 Results of CAB on such a large sample would be available
for the first time, could be used for appropriate
interventions, examining cause & effect relationship etc.
POLICY IMPLICATIONS

27. There is no substitute for a complete
Civil Registration System
 Bulk of the above information particularly fertility and
mortality indicators cross-classified by standard auxiliary
variables can be made available for all the districts if there
was a complete and up to date CRVS.
 Universal coverage under CRS will yield meaningful
information on sex-ratio at birth and still birth rate, which
would help in mapping the effectiveness of PNDT Act.
 For causes of death, this perhaps (MCCD) is the only
solution.
 The list is endless………
POLICY IMPLICATIONS

28. Thank You