ACKNOWLEDGEMENT
This maiden work on road accident, violent and external deaths would not be possible without the full collaboration of the key NSS institutions such as the Births and Deaths Registry, the Ghana Police Service, the Ghana Health Service, the Ghana Ambulance Service, the National Road Safety Commission, the Ghana Prisons Service, the National Fire Service and the National Disaster Management Organization who played various roles and provided useful inputs for the design and implementation of the project.
We express our profound gratitude to Global Grants Program under the Bloomberg Data for Health Initiative for the funding and Professor Don deSavigny for making time to also review the report. The Government Statistician and staff of GSS for the unwavering support, insights that guided the different activities.
Special thanks to Dr. Fidelia Dake for the general guidance and technical oversight and Mr. Stephen Amoah for the selfless dedication to this project even when he retired from active public service during the data collection phase.
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TABLE OF CONTENTS
FOREWORD...... ii ACKNOWLEDGEMENT ...... iii LIST OF TABLES ...... vi LIST OF FIGURES ...... vii LIST OF APPENDICES ...... viii LIST OF ABBREVATIONS ...... viii CHAPTER ONE ...... 1 INTRODUCTION...... 1 1.1 Background ...... 1 1.2 Ghana’s Mortality Statistic Project ...... 1 1.3 Objectives ...... 2 1.4 Structure of the Report ...... 2 CHAPTER TWO ...... 3 METHODOLOGY ...... 3 2.1 Technical Implementation ...... 3 2.2 Implementation Activities ...... 3 2.2.1 Business Process Mapping ...... 3 2.2.2 Development of Data Collection Tools ...... 4 2.2.3 Selection of Data Collection Points ...... 4 2.2.4 Training of Police Officers (Data Collectors) ...... 5 2.2.5 Data collection ...... 6 2.2.6 Monitoring and Supervision ...... 6 CHAPTER THREE ...... 7 RESULTS ...... 7 3.1 Overview ...... 7 3.2 Socio-demographic characteristics of reported cases of death ...... 7 3.2.1 Age ...... 7 3.2.2 Sex...... 9 3.2.3 Distribution of number of deaths by age group and sex ...... 9
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3.2.3 Marital Status ...... 10 3.2.4 Ethnicity ...... 11 3.2.5 Religious Affiliation ...... 12 3.2.6 Employment Status ...... 12 3.3 Characteristic features of road traffic, violent and external deaths ...... 13 3.3.1 Type of incident ...... 13 3.3.2 Status of post mortem investigation ...... 14 3.3.3 Registration and Burial ...... 15 CHAPTER FOUR ...... 16 LESSONS AND CHALLENGES ...... 16 4.1 Introduction ...... 16 4.2 Types of incident and stakeholder involvement ...... 16 4.3 Post mortem investigation and determination of cause of death ...... 18 4.4 Registration and issuance of burial permits ...... 20 CHAPTER FIVE ...... 21 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ...... 21 5.1 Summary ...... 21 5.2 Conclusions ...... 21 5.3 Recommendations ...... 21 5.3.1 Engaging Family/Community Members and Informants ...... 22 5.3.2 Addressing delays/challenges with coroner investigations...... 22 5.3.3 Enforcing laws and regulations ...... 22 5.3.4 Public education on the importance of registering deaths ...... 22 5.4 Next Steps ...... 22 APPENDICES ...... 24 A. BUSINESS PROCESS MAPS ...... 24 PROJECT PERSONNEL ...... 31
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LIST OF TABLES
Table 1: Sample Frame and coverage ...... 5
Table 2: Distribution of road traffic, violent and external deaths by age groups ...... 8
Table 3: Percentage distribution of deaths by status of registration, issuance of a burial permit and
release of the body for burial ...... 15
Table 4: Percentage distribution of road traffic, violent and external deaths by status
of post mortem investigation ...... 19
Table 5: Percentage distribution of reported deaths by registration status, released of body for
burial and issuance of burial permit ...... 20
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LIST OF FIGURES
Figure 1: Participants at Business Process Mapping Stakeholder Meeting ...... 4
Figure 2: Participants at Training Session ...... 6
Figure 3: Distribution of road traffic, violent and external by the sex of the deceased ...... 9
Figure 4: Distribution of cases by age and sex ...... 10
Figure 5: Percentage distribution of deaths by marital status of deceased persons ...... 11
Figure 6: Percentage distribution of deceased persons by ethnicity ...... 11
Figure 7: Percentage distribution of deceased by religious affiliation ...... 12
Figure 8: Percentage distribution of deceased persons by employment status ...... 13
Figure 9: Percentage distribution of reported cases by type of incident of death ...... 14
Figure 10: Percentage distribution of deaths by status of post mortem investigation ...... 15
Figure 11: Sample scenarios of deaths classified as undetermined ...... 17
Figure 12: Sample of deaths classified as “Other” ...... 18
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LIST OF APPENDICES
Appendix A1: Business process map for unnatural death (the case of murder) 24
Appendix A2: Business process map for the scenario of a death of a prisoner 25
Appendix A3: Business Process map for death occurring during a fire 26
LIST OF ABBREVATIONS
BPM Business Process Map
GSS Ghana Statistical Service
CRVS Civil Registration and Vital Statistics System
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CHAPTER ONE INTRODUCTION
1.1 Background
Sources of mortality statistics for policy planning in Ghana have historically emanated from statistical surveys, censuses and routine administrative data. These traditional sources of mortality data often underestimate statistics on death due to the significant proportion of deaths which occur outside health facilities; estimated at about seventy percent of all deaths. These sources of mortality data are inadequate and not without challenges. For instance, surveys and censuses provide mortality indicators periodically, while administrative data from health facilities which serve as a source of routine data augmenting the data gaps associated with prolonged intervals in the inter-censal and intermittent survey periods are not representative of the entire population. Analysis of mortality data from health facilities for 2016 for example suggest that deaths in Ghana fall under two broad classifications; (1) deaths due to communicable diseases and (2) deaths due to non-communicable diseases. However, comparative data from international sources such as the Global Burden of Disease Study, suggest a third classification - deaths due to injuries and external causes; which appears to be missing from statistics from health facilities and the civil registration and vital statistics system.
The challenges with compiling accurate mortality statistics in Ghana are partly due to the lack of proper integration of silo/parallel systems of mortality data collection by different stakeholders. Additionally, the cultural sensitivity and procedural requirements surrounding the reporting of deaths in general and deaths due to road traffic, violent and external causes in particular make it difficult to generate accurate statistics on mortality in Ghana. Statistics on deaths that occur outside health facilities in particular are either poorly recorded or largely excluded from national mortality statistics. Consequently, the quality of vital statistics on deaths in Ghana is very poor. Currently, only about seven percent of mortality data in Ghana is of good quality to be used as vital statistics. This is not only far below the internationally accepted level but also excludes data on the third classification of deaths.
As part of efforts to address the aforementioned challenges associated with generating accurate mortality statistics in Ghana, the Ghana Statistical Service (GSS) and its partners, with funding support from the Bloomberg Data for Health Initiative implemented a mortality statistics project to collect routine data on road traffic, violent and external causes of death.
1.2 Ghana’s Mortality Statistic Project
The Ghana Statistical Service (GSS) was selected to implement a mortality statistics project under the Bloomberg Data for Health Initiative Global Grants Program. The mortality statistics project primarily sought to establish a system of routine data collection on road traffic, violent and external deaths. GSS together with other stakeholders under took a series of related activities in implementing the mortality statistics project. Stakeholders who participated in the project include; the Births and Deaths Registry, the Ghana Police Service (including the Criminal Investigations Department and the Domestic Violence and Victim Support Unit), the Ghana Health Service, the Ghana Ambulance Service, the National Road Safety Commission, the Ghana Prisons Service, the National Fire Service and the National Disaster Management Organization.
The first activity that was undertaken was a consultative stakeholder meeting to develop Business Process Maps (BPMs) for the entire process of the occurrence, reporting and recording of road traffic, violent and external deaths. An iterative process was used in developing the Business Process Maps and this afforded the stakeholders the opportunity to document their various processes in detail. The BPMs that were developed for road traffic and other unnatural deaths during the stakeholder meetings are shown in Appendix A1-A3. Following the consultative business process mapping meeting, another stakeholder workshop was held to develop a data collection tool for collecting routine data on road traffic, violent and external deaths. This tool was used to train police officers from selected police stations in the Greater Accra region which constituted the sample for the initial phase of the project. The data collection instrument is included as appendix B at the end of this report.
1.3 Objectives
The mortality statistics project sought to establish a system of routine data collection for road traffic, violent and external deaths and the subsequent integration of such data into the civil registration and vital statistics system for the purposes of registration and compilation of vital statistics. The mortality statistics project also provides baseline data for subsequent mortality data collection exercises aimed at improving mortality statistics, particularly on road traffic, violent and external deaths in Ghana.
1.4 Structure of the Report
This report is organized into five main chapters. The first chapter introduces the report and includes a background on the status of mortality statistics in Ghana, a summary of the mortality statistics project, the objectives of the project and the organization of the report. The second chapter details the methodology employed in selecting data collection points, training of police officers (data collectors) and the data collection process. The third chapter presents the results while the fourth chapter discusses the lessons learned and the challenges observed. The fifth and final chapter presents the summary, conclusions and recommendations. Additional/ supplementary information where necessary, is provided in an appendix at the end of the report.
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CHAPTER TWO METHODOLOGY
2.1 Technical Implementation
The mortality statistics project was implemented through a series of inter-related activities that were undertaken collectively by several stakeholders. A stakeholder engagement process was catalytic to the entire enterprise of implementing the project. Stakeholders included personnel from the Ghana Police Service, the Ghana Statistical Service, the Ghana Health Service, the Ghana Prisons Service, the National Ambulance Service, the Ghana Prison Service and the National Road Safety Commission. These stakeholders played critical roles in developing Business Process Maps (for different scenarios of death due to road traffic, violent and external causes) and data collection instruments, training of personnel for data collection, supervising and monitoring data collection among others.
2.2 Implementation Activities
2.2.1 Business Process Mapping
Business Process Mapping involves documenting key activities that are necessary in achieving the ten key milestones in notifying, registering a vital event and generating vital statistics. A two- day stakeholder engagement aimed at developing business process maps for road traffic, violent and external deaths was organized at the initial stages of implementing the Ghana Mortality Statistics Project. This exercise was very useful as it set the pace for the rest of the project activities. The business mapping process also afforded the various stakeholders the opportunity to document in detail, the processes involved in reporting, recording and documenting information on road traffic, violent and external deaths. Stakeholders at the workshop included personnel from the Ghana Police Service, Ghana Health Service and the Ghana Prisons Service among others. Business process maps detailing the processes involved in reporting and recording deaths that occur outside a health facility from the occurrence of a road traffic, violent or external death to the final stage of compiling statistics on such deaths were developed using the Bizagi software. Business process maps for unnatural deaths, death of a prisoner, and death during a fire outbreak were developed during this stakeholder engagement. The detailed business process maps for different scenarios of deaths are shown in Appendix A1 to A3. The business process maps have been shared with internal (national) and external partners. These business process maps served as the guide for developing the data collection tool for gathering data on road traffic, violent and external deaths.
3
Figure 1: Participants at Business Process Mapping Stakeholder Meeting
2.2.2 Development of Data Collection Tools
Following the business mapping workshop, a three-day workshop was held with stakeholders to develop, review and validate a new data collection tool for collecting data on road traffic, violent and external deaths. Existing data collection tools were first reviewed thoroughly for content and relevance. A new tool was then developed based on the review of the existing tool to reflect the mortality issues that the mortality statistics project sought to address in line with the objectives of the project. The new draft tool was shared with stakeholders (internal and external) for validation and finalized based on comments from the stakeholders. The finalized tool was used to develop an application in CSpro that was used to generate an electronic version of the tool. The electronic version of the tool was loaded on tablets for administration through the Computer- Assisted Personal Interviewing (CAPI) approach.
2.2.3 Selection of Data Collection Points
The unit of sampling and analysis was police stations and divisions in the Greater Accra region. Appropriate sampling procedures, taking into consideration the organization of the hierarchy of
4 the police administrative structure were applied in selecting the data collection points. The initial phase of the project was limited to the Greater Accra region. There are two main police commands in the Greater Accra region (i.e. the Tema and Accra commands) and these commands are further divided into divisions, districts and local police stations. The various police stations and divisions in the two commands in the Greater Accra region constituted the sampling frame for the selection of data collection points (Table 1). The list of all sub-stations in the Tema and Accra commands was provided by the Headquarters of the Ghana Police Service. Balancing the constrain of financial resources with precision of the sample, a sample of 40 police stations were selected for implementation with probability proportional to size (number of sub- stations in a command) at the first stage. Simple random sampling method was used in the second stage to select the number of data collection points with equal probability in each command. For the Tema command, 12 police stations were selected and 28 stations were selected in the Accra command. Out of 40 selected stations, personnel from 38 stations reported for training. The final data were thus collected from 38 stations representing 95 percent coverage.
Table 1: Sample Frame and coverage
Police Number of sub- Number Number Coverage command stations Selected enumerated (%) Tema 31 12 11 91.7
Accra 74 28 27 96.4
Total 105 40 38 95.0
2.2.4 Training of Police Officers (Data Collectors)
In response to a written request to the Inspector General of Police (IGP), one police officer from each of the selected police stations was delegated to participate in a two-day residential training workshop which was held on 8th – 9th January, 2020 at Windy Lodge, Winneba. The purpose of the training was to equip the police officers with the necessary knowledge and skills required for the data collection exercise. The training included a mix of presentations and practical hands on sessions. The presentations covered the global and national mortality situation and the gaps and limitations of collecting mortality statistics in Ghana. There was also a detailed step by step presentation on each of the questions in the data collection instrument. This was then followed by a review of the hard copy of the tool. A follow-up practical session included a number of activities. First, there was a demonstration of an electronic version of the tool which was pre- loaded on tablets. The police officers were taken through the process of administering the electronic version of the data collection tool and this was followed by hands-on exercises. After the demonstration, the police officers took turns to conduct mock interviews on different 5 scenarios of death using the Computer-Assisted Personal Interviewing (CAPI) approach. In all, a total of thirty-eight (38) officers from the Ghana Police Service and one officer of the Ghana Prisons Service successfully completed the training. The training was facilitated by the Consultant for the project together with a Pathologist (Medical Examiner/Coroner) and technical staff of the Ghana Statistical Service and the Births and Deaths Registry.
Figure 2: Participants at Training Session
2.2.5 Data collection
The trained officers were assigned the responsibility of collecting data on all incidences of road traffic, violent and external deaths which occurred within the jurisdiction of their various stations, districts and divisional commands. Data collection commenced immediately after the training. Data on cases of road traffic, violent and external deaths reported to the police starting from 1st January 2020 were collected and synchronized to a central server at the headquarters of the Ghana Statistical Service. Data on a total of five hundred and ten cases (510) were collected between January and December, 2020.
2.2.6 Monitoring and Supervision
The project implementation team conducted monthly monitoring and supervisory visits to the various data collection points between February and May, 2020 to provide technical support and troubleshooting. Subsequent monitoring visits were bimonthly due to COVID-19 restrictions. There were also emergency visits by the IT support team in response to urgent issues whenever this became necessary.
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CHAPTER THREE RESULTS
3.1 Overview
The mortality statistics project collected data on a total of five hundred and ten (510) cases between January and December, 2020. The distribution of the cases by socio-demographic characteristics, circumstances of death, post mortem investigation and status of civil registration of the deceased person are presented in tables and charts.
3.2 Socio-demographic characteristics of reported cases of death
3.2.1 Age
The age of the deceased persons ranged from 0 to 95 years. In terms of five-year age groupings, those aged 0-4 years constituted 4.5 percent of the total number of cases. Those aged 50-54 years at the time of death constituted the highest proportion, representing 11.4 percent of the total number of cases. Those aged 90 years and older constituted the lowest proportion of the reported deaths (Table 2). The number of deaths after age 5-9 increases with increasing age to age 50-54, then starts to decline to the lowest at age 90 and older.
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Table 2: Distribution of road traffic, violent and external deaths by age groups
Age group Percentage (%) Number of cases
0-4 4.5 23
5-9 2.4 12
10-14 1.4 7
15-19 2.2 11
20-24 3.7 19
25-29 4.3 22
30-34 5.3 27
35-39 8.6 44
40-44 9.4 48
45-49 10.0 51
50-54 11.4 58
55-59 7.4 38
60-64 8.0 41
65-69 6.3 32
70-74 5.1 26
75-79 3.9 20
80-84 3.7 19
85-89 1.6 8
90-94 0.6 3
95+ 0.2 1
Total 100.0 510
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3.2.2 Sex
About two-thirds (65.6%) of the road traffic, violent and external deaths reported occurred to males while about one-third (34.6%) occurred to females (Figure 3).
Figure 3: Distribution of road traffic, violent and external by the sex of the deceased
34.6
Males
Females 65.6
3.2.3 Distribution of number of deaths by age group and sex
The results in Figure 4 further show that the number of deaths due to road traffic, violent and external causes were generally higher among males compared to females particularly in the mid- adult years.
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Figure 4: Distribution of cases by age and sex
40
35
30
Male 25 Female 20
Number Number deathsof 15
10
5
0
Age group
3.2.3 Marital Status
About half of the deceased persons were married at the time of their death and a little over one- quarter have never been married (Figure 5). Also, a little less than one-fifth of the deceased persons were divorced, separated or widowed and were thus not married or in a union at the time of death.
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Figure 5: Percentage distribution of deaths by marital status of deceased persons
53.6
27.5
18.9 Percentage(%)
Never married Married/Cohabiting Formerly married
Marital Status
3.2.4 Ethnicity
A little more than 2 out of 5 (44.2%) of the deceased persons were Akans and a little less than one-quarter (24.6%) were Ga-Dangmes (Figure 6). Ewes constituted about one-fifth (19.4%) of the total number of reported cases while Mole-Dagbani’s and people of “Other” ethnic groups constituted 6.1 and 5.7 percent respectively.
Figure 6: Percentage distribution of deceased persons by ethnicity
44.2
24.6
19.4 Percentge(%) 6.1 5.7
Akan Ga-Dangme Ewe Mole-Dagbani Other
Ethnic group
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3.2.5 Religious Affiliation
In terms of religious affiliation, about 4 out of 10 of the deceased persons belonged to the Protestant faith. Those who belonged to the Pentecostal/Charismatic faith constituted a little over a quarter (28.1%) of the total number of reported cases (Figure 7). Those belonging to the Islamic religion constituted 5.6% of all the reported cases.
Figure 7: Percentage distribution of deceased by religious affiliation
Other 6.3
Traditionalist 1.0
Muslim 5.9
Other Chirstian 5.5
Pentecostal/Charismatic 28.1
Protestant 41.5
Catholic 5.7
No religion 6.1
3.2.6 Employment Status
Figure 8 shows the distribution of the deceased persons by their employment status. A little more than one-fifth (22.8%) were not working at the time of their death and a little over one-third (35.4%) were self-employed. About 1 in 10 (9.4%) were casual workers. Only 3.1 percent of the reported cases were employees of government and other organizations.
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Figure 8: Percentage distribution of deceased persons by employment status
34.4 35.0
30.0
25.0 20.7 20.0 18.3
15.0
10.0 8.6 6.7 7.1
Percentage (%) Percentage 4.1 5.0
0.0
3.3 Characteristic features of road traffic, violent and external deaths
3.3.1 Type of incident
As depicted in Figure 9, suicides constituted the lowest proportion of all deaths representing 0.6% of all the reported cases. Deaths from homicides constituted 3.1% of the total number of reported cases while deaths from road traffic accidents constituted 6.5 percent of all the deaths. For about 6 out of 10 (61.3%) of the deaths reported, the type of incident was not classified. These unclassified deaths were mostly deaths that occurred suddenly or within 24 hours of the deceased person being admitted to a health facility. The laws of Ghana as specified in the Coroners Act of 1960 (Act 18) require that a post mortem is conducted for such deaths to determine the cause of death1. Additionally, deaths occurring in the community, outside a health care facility are considered as falling under the jurisdiction of a coroner1 and such deaths are required to undergo post mortem investigation to determine the cause of death. Furthermore, deaths deemed to be due to unnatural circumstances such as homicide, suicide, accident or misadventure require further investigation under the coroner system to determine the cause of
1 Anim JT (2015) Autopsy Practice in Ghana - Reflections of a Pathologist. Ghana Med J 49:112–119 13 death. Another set of deaths classified as “Other” constituted about a third of the reported cases. Some of these “other” deaths include cases that did not fall under any of the categorization as shown in Figure 9.
Figure 9: Percentage distribution of reported cases by type of incident of death
70 61.3 60
50
40 28.5 30
20
Percentage(%) 6.5 10 3.1 0.6 0 Accident Suicide Homicide Unclassified Other
Type of incident
3.3.2 Status of post mortem investigation
The results in Figure 10 reveal that while about forty-six percent of the road traffic, violent and external deaths underwent a post mortem investigation to determine the cause of death, an almost equal proportion (45.7%) did not undergo a post mortem investigation. Additionally, post mortem investigation was delayed for 7 percent of the deaths. For a small proportion of the deaths, the investigator/informant did not know if a post mortem investigation had been conducted.
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Figure 10: Percentage distribution of deaths by status of post mortem investigation
46.1 45.7
6.9 1.3
Post mortem condcuted Post mortem not Post mortem delayed Don't know conducted
3.3.3 Registration and Burial
The results presented in Table 3 show that more than half (52.7%) of the road traffic, violent and external deaths have not been registered with the civil registration authority. Consequently, a burial permit has not been issued for the burial of the remains of more than half (51.7%) of the deaths. However, the bodies of more than half (59.5%) of the deceased persons have been released to the respective families for burial.
Table 3: Percentage distribution of deaths by status of registration,
issuance of a burial permit and release of the body for burial
Death registered 47.3 Death not registered 52.7
Burial permit issued 48.0 Burial permit not issued 51.7
Body released for burial 59.5 Body not released for burial 40.5
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CHAPTER FOUR LESSONS AND CHALLENGES
4.1 Introduction
Ghana’s mortality statistics project aimed to establish a system of routine data collection for road traffic, violent and external deaths and the subsequent integration of such data into the civil registration and vital statistics system for the purposes of registration and compilation of vital statistics. The project also attempted to harmonize existing parallel systems of data collection on this core but missing component of Ghana’s mortality statistics. This initial phase of the project was implemented in selected police stations and divisions in the Accra and Tema police commands in the Greater Accra region.
4.2 Types of incident and stakeholder involvement
The process involved several stakeholders with the police serving as the primary point of data collection. Data were collected on different incidents of death specifically targeting road traffic, violent and external deaths. The results indicate that the majority of the reported cases were deaths that occurred less than twenty-four hours or on arrival at a health facility. Figure 9 presents some examples of the scenarios of how such deaths occurred. Deaths from external and violent causes were also reported as presented in the excerpts from the following narratives;
The deceased [xxx] was attacked, stabbed on his left chest with knife cuts on his forehead by unknown person/persons [E1, Violent death]
He went to a riverside and got drowned. He was rescued and rushed to [xxx] Government Hospital for treatment but died on arrival [E2, External death].
Additionally, deaths from road traffic accidents constituted about 7 percent of all the reported cases. The deaths from road traffic accidents occurred to both pedestrians “ v ictimwas w alking along the side of the road on her way to work when she was hit by a Truck which crashed her head at [xxx]” and passengers who were travelling in vehicles “she was on board a vehicle which was involved in accident at [xxx]. She died on arrival at [xxx] Hospital.
16
A characteristic feature of the reported cases was that, regardless of the type of incident, the police played a critical role in collecting data on the various incidents. However, other stakeholders were also involved in the entire process of reporting and recording vital information regarding such deaths. In most cases, the family and community members were the first step in the process and they played the critical role of informing the police about the occurrence of such deaths.
Figure 11: Sample scenarios of deaths classified as undetermined
[E3] aged 86 years complained of ill- health and was rushed to Police Hospital but was pronounced dead on [E4], family member arrival on [E2], husband of the told police that, the 05/01/2020 at about deceased told the deceased fell sick and 2300 hours. police that, the wife was rushed to the reported sick and was Weija/Gbawe taken to Municipal Hospital but Weija/Gbawe was pronounced dead Municipal Hospital few hours after arrival. but died few hours later. Scenarios of Undetermied deaths [E1] came to the [E5] Deceased was station and reported from work at Sampa that her father who and on reaching St. has been suffering Johns, he fainted and from diabetes fell was quickly rushed to unconcious and was the Ashongman [E6] She has been rushed to the hospital but was suffering from stroke Amasaman hospital but was pronouced pronouced dead on for sometime now but dead on arrival. arrival. on 08/04/2020 her condition worsened and was rushed to Amasaman Hospital for treatment but died while on admission.
17
Figure 12: Sample of deaths classified as “Other”
[E3] Deceased who has never been diagnosed of any chronic ailment was found dead in her room on 25/05/2020 [E2] Deceased in her residence [E6] Found died at home and lying dead police was behind the informed for fence wall of assessment. XXX Other deaths [E5]The deceased [E1] He was was a lone private treated and security guard on discharged on duty, but was 20/05/2020. He found dead outside was found dead [E4] He was found the post on a same day in his lying dead at bench. room. Amasaman - Aborkope infront of a neighbour's house without any mark of assault.
4.3 Post mortem investigation and determination of cause of death
Cause of death statistics is important for improving population health and for health policy and planning. Accurate statistics on cause of death is therefore essential for any civil registration and vital statistics system. Ghana’s CRVS system has been challenged by the poor quality of vital statistics for several years. Currently, only about 6 percent of the causes of death data for deaths occurring in health facilities are of good quality to be used as vital statistics. This source of vital statistics often excludes deaths from road traffic, violent and other external causes of death. However, estimates based on international data sources such as the Global Burden of Disease study show that about 10 percent of the deaths in Ghana should be due to road traffic, violent and external deaths, yet there are no routine sources of data for such estimation.
Against the foregoing, the mortality statistics project sought to investigate whether post mortem investigations were carried out to determine the cause of death for the reported cases. The results indicate that post mortem investigations had not been conducted for about 46% of the reported cases, although the law requires that a coroner investigation is conducted for all such deaths. The analysis further shows that, suicide/homicides deaths were more often investigated by a coroner (Table 4). Post mortem investigations were also conducted for deaths from road traffic accidents. 18
However, about half (50.7%) of the deaths that were unclassified and a little more than 4 out of 10 of the deaths classified as “other” were not investigated by a coroner. Additionally, cause of death investigation was delayed for between 7 and 8 percent of the deaths that were unclassified or due to other types of incidents (Table 4).
Table 4: Percentage distribution of road traffic, violent and external deaths
by status of post mortem investigation
Status of post mortem investigation (%)
Type of incident Post mortem Post mortem not Delayed Don't conducted conducted know
Road traffic accident 63.6 24.2 6.1 6.1
Suicide 33.3 66.7 0.0 0.0
Homicide 87.5 12.5 0.0 0.0
Unclassified 40.7 50.7 7.0 1.5
Other 47.9 44.4 7.6 0.0
A number of reasons account for the lack or delay in conducting post mortem investigations as required by the law. The first and most common reason has to do with administrative/procedural issues. These included pending authorization to conduct the investigation or waiting for a date to schedule the autopsy or an investigation being in the process but not completed. In a few of the cases, the coroner investigation has been completed but the results were not available. Secondly, coroner investigations were not conducted because the family of the deceased person did want to have the autopsy investigation conducted. Some families did not see the need for an autopsy and a few others cited the cost associated with conducting the autopsy as the reason why they did not agree for the procedure to be done. The third most cited reason was on religious grounds. Respondents of the Islamic faith do not agree to have post mortem investigations conducted on their deceased relatives because of their religious beliefs.
It is important to address these issues to ensure compliance with the legal requirement to conduct an autopsy to determine the cause of death for road traffic, violent and external causes of death to generate quality vital statistics to inform health policies and planning. Furthermore, addressing
19 cost and religious barriers could help increase acceptance and compliance of post mortem investigations.
4.4 Registration and issuance of burial permits
Similar challenges with conducting autopsies were observed with the registration and issuance of burial permits. Although the laws of Ghana require that every death is registered and certified and a burial permit issued prior to burial, the results of the current project found that more than half (52.7%) of the deaths were not registered and a burial permit has not been issued for more than half (51.7%) of the deaths. Further analysis indicates that a little more than one-third (36.5%) of the deaths which had not been registered had been released for burial (Table 5). Furthermore, a burial permit had not been issued for 13.2% percent of deaths that have been registered. This is plausible if the burial of the remains of the deceased will be buried in a district other than the district in which the death was registered to have occurred. In such an instance, a burial permit will be issued in the district in which the burial will take place. This notwithstanding, these gaps in registration and issuance of burial permits limit the chances of optimal registration of deaths and generation of quality vital statistics. There is the need for further investigation into these gaps in the registration of not only road traffic, violent and external deaths but deaths in general. The findings of such investigations will inform appropriate interventions and policies that will help address these challenges and improve Ghana’s civil registration and vital statistics system especially in the area of mortality statistics.
Table 5: Percentage distribution of reported deaths by registration status,
released of body for burial and issuance of burial permit
Issuance of burial Release of body for burial permit (%) (%) Row Total Registration Status Burial Burial Body Body not (%) permit permit not released released issued issued Death registered 86.8 13.2 85.0 15.0 47.3 Death not registered 13.5 86.5 36.5 63.5 52.7 Column Total (%) 48.3 51.7 59.5 40.5 100.0
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CHAPTER FIVE SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
5.1 Summary
The Ghana mortality statistics project aimed to establish a system of routine data collection for road traffic, violent and external deaths. The project brought together stakeholders from the Ghana Police Service, the Ghana Statistical Service, the National Road Safety Commission, the National Ambulance Service and the Ghana Prisons Service among others. The stakeholders worked on developing business process maps for the entire process of the occurrence of a road traffic, violent or external death to generation of vital statistics for the same. The stakeholders also developed a tool that was used to collect data on road traffic, violent and external deaths. Officers of the Ghana Police Service from selected stations/divisions in the Accra and Tema commands in the Greater Accra region were trained to collect routine data on the road traffic, violent and external deaths that were reported to the various stations. A total of thirty-eight (38) officers were trained and data were collected on a total of five hundred and ten cases (510) between January and December 2020.
5.2 Conclusions
The findings from the business process mapping indicate that the process of reporting, recording and compiling statistics on road traffic, violent and external deaths involves several stakeholders although the police play the central/key role in collecting and recording the necessary data on such deaths. Analysis of the data shows that road traffic, violent and external deaths occurred across all age groups and about two-thirds of the deaths occurred to males. Furthermore, more than half of the deaths were unclassified cases and these were mostly deaths that occurred less than 24 hours after admission to a health facility or dead on arrival at a health facility. Road traffic deaths constituted about 7 percent of all the reported deaths while suicide constituted the least proportion of 0.6%. The results further reveal that post mortem investigations had not been conducted for more than half of the deaths and the reasons were mostly due to administrative challenges and partly due to cost and religious barriers. Additionally, more than half of the deaths have not been registered but more than half of the bodies had been released for burial. This creates missed opportunities for registering and certifying such deaths.
5.3 Recommendations
Based on the findings of the mortality statistics pilot project, a number of recommendations that will help improve Ghana’s mortality statistics are proposed. Just as the current reporting and registration system involves several stakeholders, the recommendations for remedying the
21 challenges identified also involves different stakeholders who need to play their respective roles effectively.
5.3.1 Engaging Family/Community Members and Informants
Firstly, the link between the police and the community/family members needs to be strengthened to ensure that all incidents of road traffic, violent and external deaths are reported to the police as required by law. The general community/family needs to be educated on the importance of reporting road traffic, violent and external deaths to the police and providing the necessary information when reporting such cases.
5.3.2 Addressing delays/challenges with coroner investigations
Secondly, there is the need to develop detailed business maps for the coroner investigation process to identify the challenges and bottlenecks in the system. This could help to reduce the delays in conducting autopsies and determining the cause of death to facilitate registration and certification of deaths due to road traffic, violent and external causes.
5.3.3 Enforcing laws and regulations
Thirdly, there is the need for stricter law enforcement to ensure compliance with the law on issuance of burial permits prior to interment. This could help to improve the level of death registration and subsequent compilation of vital statistics particularly on cause of death.
5.3.4 Public education on the importance of registering deaths
Fourthly, there is the need for public education to create awareness on the importance or registering deaths and getting a burial permit prior to interment, most especially if the death is a road traffic, violent or external death.
5.4 Next Steps
The findings of this project reveal the need for further investigations in some aspects of Ghana’s mortality data systems. For example, there is a need for detailed investigation into why more than half of reported cases did not undergo post mortem investigations or were not registered with the civil registration authority. The next phase of the project will attempt to answer these questions in a national scale-up that will implement specific targeted interventions. Firstly, detailed business process maps for the coroner system will be developed to among other things document the step by step process involved in conducting an autopsy for unnatural deaths, identify gaps and bottlenecks in coroner system and develop targeted solutions to improve the system. Secondly, nationwide data collection on road traffic, violent and external deaths will provide national empirical data that will be useful for designing policy/intervention as well as providing benchmark data for future projects. Thirdly, data linkage between the police system,
22 the coroner system and the civil registration system could be explored to integrate the various parallel/silo system into one robust synergistic system.
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APPENDICES
A. BUSINESS PROCESS MAPS
Appendix A1: Business process map for unnatural death (the case of murder)
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Appendix A2: Business process map for the scenario of a death of a prisoner
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Appendix A3: Business Process map for death occurring during a fire
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Appendix B: DATA COLLECTION INSTRUMENT
DATA COLLECTION INSTRUMENT FOR ROAD TRAFFIC, VIOLENT AND EXTERNAL DEATHS QUESTION QUESTION/ITEM CODES SKIP NUMBER
SECTION 1: IDENTIFICATION
ID1 REGION OF OCCURRENCE OF INCIDENT
ID2 DISTRICT OF OCCURRENCE OF INCIDENT
ID 3 LOCALITY OF OCCURRENCE OF INCIDENT
SECTION 2: DETAILS ABOUT DECEASED PERSON
Q1 NAME
Q2 AGE
Q3 DATE OF BIRTH DD ___MM ____ YEAR ______
Q4 DATE OF DEATH DD ___MM _____ YEAR ______
1. MALE Q5 SEX 2. FEMALE
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Q6 ETHNICITY
Q7 RELIGOIUS AFFILIATION
Q8 NATIONALITY
Q9 MARITAL STATUS
Q10 EMPLOYMENT STATUS
Q11 DISTRICT OF RESIDENCE
Q12 REGION OF RESIDENCE
SECTION 3: CHARACTERISTICS OF INCIDENT
Q13 DID THE INCIDENT OCCUR INDOOR OR 1. INDOOR
2. OUTDOOR OUTDOOR 1. ACCIDENT Q14 TYPE OF INCIDENT 2. SUICIDE
3. HOMICIDE
4. UNDETERMINED
5. OTHER
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Q15 CIRCUMSTANCE OF DEATH
(WRITE NARRATIVE)
Q16 WAS THE DECEASED IDENTIFIED BY A 1. YES
2. NO FAMILY MEMBER?
Q17 WAS A POSTMORTEM CARRIED OUT? 1. YES IF YES Q18
2. NO
3. DELAYED
4. DON’T KNOW IF NO, DELAYED
OR DON’T KNOW
Q20
Q18 WHAT IS THE POST MORTEM (PM) PM NUMBER ______NUMBER?
Q19 WHAT WAS THE CAUSE OF DEATH (COD)? COD______
Q20 WHY WAS A POSTMORTEM NOT DONE? REASON(S) ______1. YES Q21 HAS THE DEATH BEEN REGISTERED? IF YES Q23 2. NO
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Q22 WHY HAS THE DEATH NOT BEEN REASON(S) REGISTERED? ______
1. YES Q23 HAS A BURIAL PERMIT BEEN ISSUED BY 2. NO THE BIRTHS AND DEATHS REGISTRY?
Q24 HAS THE BODY BEEN RELEASED FOR 1. YES IF YES END
BURIAL? 2. NO OF
QUESTIONNAIRE
IF NO Q24
Q25 WHY HAS THE BODY NOT BEEN REASON(S) REALEASED? ______
NAME OF OFFICER: ______
DEPARTMENT: ______
SIGNATURE: ______
DATE OF COMPLETING QUESTIONNAIRE: DD______MM______YEAR ______
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PROJECT PERSONNEL
Project Implementation Team Dr. Fidelia Dake Consultant, Global Grants program Bloomberg Data for Health Initiative Ghana
Mr. Stephen Amoah Focal Person & National CRVS Coordinator Ghana Statistical Service
Mr. Emmanuel Opoku-Addo Focal Person, CRVS Ghana Statistical Service
Dr. Emmanuel Dwamena Sasu Institutional Team Member Ghana Statistical Service
Ms. Jane Geraldo-Acolatse Institutional Team Member Ghana Statistical Service
Mr. Festus Manuh Institutional Team Member Ghana Statistical Service
List of stakeholders Ghana Statistical Service
Ghana Police Service
Ghana Prisons Service
Ghana Health Service
Births and Deaths Registry
National Ambulance Service
National Disaster Management Organization
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National Road Safety Commission
Judicial Service
Motor Traffic and Transport Division
Training Team Facilitators
Dr. Fidelia Dake Consultant, Global Grants program
Bloomberg Data for Health Initiative Ghana
Dr. Foster Gbagbo Pathologist,
Korle Bu Teaching Hospital, Ghana Health Service
Mr. Stephen Amoah Focal Person & National CRVS Coordinator
Ghana Statistical Service
Dr. Emmanuel Dwamena Sasu Institutional Team Member
Ghana Statistical Service
Mr. Emmanuel Opoku-Addo Focal Person, CRVS
Ghana Statistical Service
Ms. Jane Geraldo-Acolatse Institutional Team Member
Ghana Statistical Service
Mr. Festus Manuh Institutional Team Member
Ghana Statistical Service
Mr. Kwamena Leo Arkafra Data Manager
Ghana Statistical Service
32
Report Writing Team Dr. Fidelia Dake Consultant, Global Grants program
Bloomberg Data for Health Initiative Ghana
Mr. Stephen Amoah Focal Person & National CRVS Coordinator
Ghana Statistical Service
Mr. Emmanuel Opoku-Addo Focal Person, CRVS
Ghana Statistical Service
Dr. Emmanuel Dwamena Sasu Institutional Team Member
Ghana Statistical Service
Ms. Jane Geraldo-Acolatse Institutional Team Member
Ghana Statistical Service
Mr. Festus Manuh Institutional Team Member
Ghana Statistical Service
Reviewers Dr. Foster Gbagbo Pathologist,
Korle Bu Teaching Hospital, Ghana Health Service
Professor Samuel K. Annim Government Statistician, Ghana Statistical Service
Mr. Omar Seidu Head, Demographic Statistics and SDGs Coordinator, Ghana Statistical Service
Mr. Anthony Pharin Amuzu Director, Social & Demographic Statistics, Ghana Statistical Service
Professor Don deSavigny Emeritus Professor of Health Systems
Swiss Tropical and Public Health Institute
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LIST OF POLICE OFFICERS NAME OF PERSONNEL DISTRICT STATION
Accra Command
Frimpong Eric Accra Central Accra Central
Ivan Owusu - Sakyiamah Ministries Ministries
Samuel Obeng Nima Nima
Owusu Dominic Kotobabi Kotobabi
Osal Kofi Adabraka Adabraka
John Baptist Angsomwine East Legon East Legon
Abigail Adutwum Tesano Tesano
James Kwesi Adjei Jnr Achimata Mile 7 Isreal
Mahmoud Baidoo Birikorang Amasaman Amasaman
Stephen Darko Nyinaku Adjen-Kotoku Adjen-Kotoku
Nicholas Komla Defoe Madina Madina
Agyekum Hayford Kwabenya Atomic Hill
Christopher Arhinful Oyibi Appolonia
Anthony Zumoh-Baligi Nungua/ Kpeshie Nungua
Samuel Dadzie Teshie Teshie
Osei Kwame Jones Darkumah Darkumah
Offei Nicholas Odorkor Gwawe- Lafa
Owusu Ansah Felix Anyaa Anyaa
Manasseh Simon Amanfrom Amanfrom
Bismark Adjei Kokrobite Kokrobite
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Newland K. Kuatsikor Dansoman Dansoman
Obed Coffie Korle-bu Korle-bu
Anthony Ackah Mamprobi Chokor
Tetteh Kingsford Richard Cantoment Cantoment
Abukari Bashiru Osu Osu
TEMA COMMAND
Dorgbadzi Foster Sakumono Sakumono
Ebenezer Marvin Kwablah Community 18 Akonoku
Samuel Nyarko Batsonaa Batsonaa
Micheal Asante Community 1 Community 1
Ato Boison Adagbila Community 2 Community 2
Peter L. Dassah Community 25 Community 25
Jean Kpeli Railways & Port Fishing Harbour
Philip B. Parimah Ashaiman Lebanon- Tsubleo
Frank Osei Adjei-Kojo Kaneshie
Evenlyn Barson Prampram Trasaco, Tema
Richard Gyampoh Dodowa Ayikuma
Bukari Ibrahim Doryuwu- Asutsuare-Osudoko Doryumu
Joseph K. Baba Ada Kasseh
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