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Experiences, Challenges and Lessons Learnt in Papua New Guinea

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Practice BMJ Glob Health: first published as 10.1136/bmjgh-2020-003747 on 3 December 2020. Downloaded from Mortality surveillance and verbal autopsy strategies: experiences, challenges and lessons learnt in Papua New Guinea 1 1 2 3 4 John D Hart , Viola Kwa, Paison Dakulala, Paulus Ripa, Dale Frank, 5 6 7 1 Theresa Lei, Ninkama Moiya, William Lagani, Tim Adair , Deirdre McLaughlin,1 Ian D Riley,1 Alan D Lopez1 To cite: Hart JD, Kwa V, ABSTRACT Summary box Dakulala P, et al. Mortality Full notification of deaths and compilation of good quality surveillance and verbal cause of death data are core, sequential and essential ► Mortality surveillance as part of government pro- autopsy strategies: components of a functional civil registration and vital experiences, challenges and grammes has been successfully introduced in three statistics (CRVS) system. In collaboration with the lessons learnt in Papua New provinces in Papua New Guinea: (Milne Bay, West Government of Papua New Guinea (PNG), trial mortality Guinea. BMJ Global Health New Britain and Western Highlands). surveillance activities were established at sites in Alotau 2020;5:e003747. doi:10.1136/ ► Successful notification and verbal autopsy (VA) District in Milne Bay Province, Tambul- Nebilyer District in bmjgh-2020-003747 strategies require planning at the local level and Western Highlands Province and Talasea District in West selection of appropriate notification agents and VA New Britain Province. Handling editor Soumitra S interviewers, in particular that they have positions of Provincial Health Authorities trialled strategies to improve Bhuyan trust in the community. completeness of death notification and implement an Additional material is ► It is essential that notification and VA data collec- ► automated verbal autopsy methodology, including use of published online only. To view, tion activities are integrated into official staff duties, different notification agents and paper or mobile phone please visit the journal online from national and provincial administrators to health methods. Completeness of death notification improved (http:// dx. doi. org/ 10. 1136/ workers and ward- level notifying agents. bmjgh- 2020- 003747). from virtually 0% to 20% in Talasea, 25% and 75% ► Following civil registration and vital statistics (CRVS) using mobile phone and paper notification strategies, stakeholder discussions in PNG, we identify the key respectively, in Alotau, and 69% in Tambul- Nebilyer. steps required to establish a functional mortality JDH and VK contributed equally. We discuss the challenges and lessons learnt with http://gh.bmj.com/ surveillance system in PNG, and present this blue- implementing these activities in PNG, including logistical print as online supplemental material. Received 18 August 2020 considerations and incentives. Revised 25 October 2020 ► Health workers should be the agents responsible Our experience indicates that strategies to maximise Accepted 10 November 2020 for electronic entry of notification and cause of completeness of notification should be tailored to the local death data into PNG’s eNHIS (electronic National context, which in PNG includes significant geographical, Health Information System) platform, as identified cultural and political diversity. We report that health by government stakeholders in CRVS business on September 27, 2021 by guest. Protected copyright. workers have great potential to improve the CRVS process maps, and endorsed by the national CRVS programme in PNG through managing the collection of Committee (business process maps are included as notification and verbal autopsy data. In light of our findings, online supplemental material). and in consultation with the main government CRVS ► Facilitating health workers to manage notifications stakeholders and the National CRVS Committee, we make and conduct VAs, with data shared between the recommendations regarding the requirements at each level National Department of Health and PNG Civil and of the health system to optimise mortality surveillance in Identity Registry, could greatly improve the country’s order to generate the essential health intelligence required CRVS programme. for policy and planning. © Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY-NC. No commercial re- use. See rights functioned mostly for expatriates living in and permissions. Published by INTRODUCTION colonial administrative centres and restricted BMJ. The civil registration and vital statistics government stations. PNG’s Civil Registration For numbered affiliations see (CRVS) system in Papua New Guinea (PNG) Act of 1963 was based largely on Australia’s end of article. is largely ineffective and there are multiple Queensland state law and does not provide Correspondence to challenges to creating a system with complete a sound basis for a functional modern CRVS Dr John D Hart; birth and death registration. Prior to inde- system for the country. As the value of reli- john. hart@ doctors. org. uk pendence in 1975, the country’s CRVS system able, timely and relevant mortality data Hart JD, et al. BMJ Global Health 2020;5:e003747. doi:10.1136/bmjgh-2020-003747 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003747 on 3 December 2020. Downloaded from becomes increasingly apparent, a new Civil Registration of the epidemiological transition has been overesti- Bill (CR Bill) has been drafted and is due to be read in mated by GBD (unpublished data). In addition, the VA parliament in 2021, that will facilitate the use of modern results emphasise the epidemiologically diverse nature of data systems and streamlined notification strategies. In mortality trends across the surveillance sites. addition, PNG has opened civil registry offices in many The optimal operational characteristics of data collec- provinces and has mobile teams as part of a current drive tion systems, such as death notification and VA, partic- to rollout National Identification (NID) cards to all citi- ularly in a society as diverse as PNG, require careful zens. While NID rollout is a government priority, there is selection and evaluation, building on local community growing high level recognition of the importance of birth structures as much as possible. In this paper, we describe and death notification and registration to produce useful a series of interventions that were implemented to vital statistics data, particularly given the importance of generate policy- relevant data to guide health develop- death notification for the deletion of NID cards to mini- ment in the country, our successes as well as challenges mise their fraudulent use. and attempted solutions. Based on the lessons learnt, we We have been working with the government of PNG draw conclusions about how best to address some of the to develop the CRVS system, in particular with the multiple challenges facing the further development of National Department of Health (NDOH) to support CRVS systems in PNG. mortality surveillance. Prior to the intervention, the vast majority of mortality data for PNG were derived from health facility discharge summaries, producing biassed DEATH NOTIFICATION estimates largely not accounting for approximately 75% We implemented strategies to improve death notification of deaths that occur in the community and are almost in PNG in three districts starting in 2018. Districts were entirely unregistered.1 In addition, the discharge summa- selected from three of PNG’s four regions: the High- ries do not record cause of death in the internationally lands Region, Islands Region and Southern Region, each recognised manner on a Medical Certificate of Cause with their own rich diverse cultural and political circum- of Death (MCCOD) and therefore coding of an under- stances. Intervention sites were not selected to be repre- lying cause of death is not possible, resulting in lower sentative of the country but rather to identify challenges quality records of limited value for policymakers. We associated with working in different regions in order to have supported physician training to improve the quality inform future planning and implementation of govern- of MCCODs and also the introduction of verbal autopsy ment programmes. The three districts were: Alotau in (VA), a technique for inferring most likely cause of death Milne Bay Province; Talasea in West New Britain Province; for unattended deaths from an interview with a relative and Tambul- Nebilyer in Western Highlands Province. of the deceased.2 The underlying strategy in all intervention sites was for PNG is in the process of expanding an electronic community- level notifying agents to inform the nearest National Health Information System (eNHIS) that is health centre of any deaths in their designated area and intended to collect individual level data from health for these to then be followed up by health workers to http://gh.bmj.com/ centres and hospitals, ideally forming the basis of a verify the data, complete an electronic notification form modern and comprehensive mortality surveillance and conduct a VA. system. A major challenge in the development of such In two intervention districts, Alotau and Talasea, Ward a system is gathering data on the ‘fact’ of deaths occur- Recorders (WRs) were selected as notification agents. ring in the community, to then use VA methodology to The WR system was first introduced across PNG under the reliably and quickly diagnose causes of death. Very little Department of Provincial and Local Government Affairs on September
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