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Health Statistics Reporting in MaldivesBy: Ms.Mariyam Mohamed & Ms.Ummeedha Abdul RazzagMinistry of Health & GenderRepublic of Maldives MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHMinistry of HealthRepublic of MaldivesMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH1I: Civil Registration and Vital Statistics (CRVS) system in MaldivesMaldives An overview

Structure of Health System

Contents of the Annual Health Report / Maldives Health Statistics

Data compilation and Analysis

Format of Presentation / Dissemination

Areas for Improvement

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHIn this presentation we will be highlighting the following areas 2MALDIVES AN OVERVIEWTotal of 1192 islands187 inhabited islandsPopulation-298,968 (Census 2006) 341848 (2014)Infant Mortality Rate 9 per 1000 live births 2012 (The Maldives Health Statistics 2014 draft )Maternal Mortality Ratio- 13 per 100,000 live births (The Maldives Health Statistics 2014 draft )Under Five Mortality Rate - 11 per 1000 live births (The Maldives Health Statistics 2014 draft )Life expectancy at birth:Male: 73.0 (2012)Female: 74.8 (2012)(The Statistical Yearbook of Maldives, 2014)

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH3Health System of Maldives

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHCCHDC has been changed to HPA41CENTRAL2REGIONAL3ATOLL4SUB-ATOLL5ISLANDSTRUCTURE OF HEALTH SYSTEM (previous)Department of Public HealthDepartment ofMedical ServicesMaldives Food andDrug AuthorityIndira GandhiMemorial HospitalNational ThalassaemiaCentreRegional HospitalsAtoll HospitalsHealth Posts & Family Health SectionsNational HealthLaboratoryHealth CentresMINISTRY OF HEALTH & GENDERMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH5Figure 1: VRS FLOW DIAGRAM

Birth / Death OccursBirth Form / Death form (Triplicate copy forms)White CopyYellow CopyPink CopyParent/ Guardian Department of National Registration (DNR)Island administration responsible for death registration/ Male MunicipalityIsland Councils /Atoll Council/ DNR MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

From 2003, a triplicate copying system of reporting births and deaths through birth form and death certificate has been operational. The original copy of the form goes to the parent or guardian, second copy is passed to the island administrations (to Municipality in case of Male). The third copy is sent to DNR, which is used to input data in the VRS database.

6Occurrence of a birthOccurrence of deathFill in the birth formTriplicate copying of the formsDepartment of National Registration (DNR)Island Office or Councils/ Male City CouncilFill in the death form (death certificate)Parent / GuardianMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

If a birth ocuured in male the capital city it shoud be informd to male city council 7Island CouncilsHealth facilitiesAtoll CouncilsDatabase of all births and deaths in the countryRegistry of all births/ deathsPhoto copyRegistry of all births/ deaths in the atollMinistry of Health & GenderRegistry of all births/ deaths in the islandDepartment of National Registration (DNR)Records of all registered birthsRecords of all deathsMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

This is a detailed of the prv one8Photo copyBirthDeathFill in the birth formFill in death formDept. National Registration Island CouncilsParent / guardianHospitalsHealth Centres (TBAs)FoolhumasIsland OfficesAtoll CouncilsMaleMale City CouncilMaleMaleMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH9Contents of the Annual Health Report / Health StatisticsNatalityMortalityMorbidity / Health ServicesHuman ResourcesHealth Care FinanceOthersMDG Indicators incorporated within sectionsNHA very limited baseline data

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHIn Maldives the health reports were published annually up until year 2004. However, at present we have the Maldives Health Statistics with only the statistical tables. In this presentation we will be focussing on Maldives Health Statistics. Looking at the contents of our health statistics there are 6 main categories. In the Natality Category, we have indicators such as Crude Birth Rate, and detailed information such as the Number of Live births, live and still births by place of occurrence, percentage of births by mode of delivery, deliveries by type of health professional.

In the Mortality Section we have the basic mortality indicators such as the Crude Death Rate, IMR, U5MR,NMR MMR, Still Birth Rate, Age specific mortality rateetc.

In the morbidity and health services section, we have information such as the prevalence and incidence of certain diseases such as the TB, Leprosy, diarrhoea,. Also we have information on HIV status, vaccine coverage reported number of dengue cases etc

The Human resource section of the Health Statistics has information on the number of health care professionals by locality and distribution of medical staff in atolls and in Male

IN the Health Care Finance Section we have information on the government budget on health sector and government health expenditure.

Lastly we have an OTHERS category which includes information on the Contraceptive PR, Drug abuse cases and imports of tobacco

AS CAN BE SEEN SOME OF THE MDG INDICATORS ARE INCLUDED IN THE DIFFERENT SECTIONS OF THE HEALTH STATISTICS IT HAS TO BE NOTED THAT OUR NATIONAL HEALTH ACCOUNT SYSTEM REQUIRES IMPROVEMENT AND THERE IS A LIMITATION TO THE BASELINE DATA FOR NHA.

SINCE THIS IS OUR FIRST HEALTH STATISTICS BOOK SOLELY FOCUSSING ON STATISTICS WE THINK THAT THERE WILL BE REVISIONS AND MUCH IMPROVEMENTS FOR THE NEXT PUBLICATION ,10Data compilation and AnalysisData collected at :Peripheral Health Care facilitiesHospitals / Health Centres / Health PostsData compiled :Ministry of Health & Gender Planning and International Health Section/Health Protection Agency/Regional HospitalsData Analysis Previously Annual Health Reports published Currently Maldives Health Statistics publishedHealth Reports to be published every five years detailed analysis of trendsMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHDATA is collected for statistics through all levels. In the peripheral atoll level, data is collected in all health care facilities, Hospitals, Health Centres and Health Posts

DATA is COMPILED at the central and regional level. At the central level data compilation is mainly done the Health Information and Research Section of the Ministry of Health & Gender

Data is also compiled from the central level at the HPA and DMS. At peripheral level, ifnormation flows from the island level to regional hospitals for data compilation

Data Analysis is very limited as currently the MoH publishes just the statistical tables with a small executive summary for the Maldives Health Statistics. Detailed analysis of the trends are to be in the Health Report which will be published every 5 years in future. This would allow us sufficient time to see the trends and analyse comprehensively

11Topics and themes covered by VSVital Statistics:Crude Birth Rate / Crude Death Rate / Infant mortality rate/ Neonatal Mortality Rate /Under5 mortality rate/ Maternal mortality rate /still birth rate/teenage pregnancies/mode of delivery/ cause od death / Age specific Mortality rate/etc are calculatedAnnual statistics published with gender disaggregation Stats are taken by locality /island /atoll wise and gender disaggreagtedVRS is the main source of vital stats.Since VRS is complete ,Census and other surveys not used to collect vital stats ,however Census is conducted in every 5yrs

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

Other than health stat book we analise data for the UN demographic year book and SYB by dnp12Format of Presentation / DisseminationMaldives Health Report & Maldives Health StatisticsPublished (last one published in 2012)Printed in hard copyElectronic Form availableOn CDOn Websitewww.health.gov.mvUsed for policy making and for other purposes including for use by government and students.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHBoth Maldives Health Statistics and Maldives Health Report is published and printed in hard copy. The electronic form is also available on CD and on the website www.health.gov.mv

13Areas for Improvement

Improved Data CollectionTimely Information

Strengthened Reporting SystemStandards developed

Capacity BuildingAt central levelAt Regional / Atoll Level

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHThere is a lot to be improved we need to improve the data collection at the peripheral level in a more timely manner.

Reporting system to the data compilation points need to be strengthened.

Furthermore we need to build the capacity at different levels to have a quality statistics in Maldives.

14Major changes / reforms in the CRVS in Maldives during the last decade

Functioning of CRVS

Coordination in CRVS

Topics and themes covered by Vital Statistics

Quality assessment and assurance in Vital Statistics

II: Changes / Reforms in CRVS in the last decadeMINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH15Coordination in CRVS100% coverageICD coding

1992 legislation still continues in birth registration The system will catch all the entries and get access toDNR / MoH&G Online system is hosted by NCIT Present change VRS data entry work moved to DNR in June 2011Online system functioning only in central level

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH16Quality assessment and assurance in VSICD training has given to Drs in the IGMH and coders have been trained in different regions (working in different hosps)Cause of death validation studyVRS assessment VRS completeness studyRegular checking of data in the forms

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHFunctioning of CRVSTriplet copies introduced in 2003 - Copies of the original forms to central level for records

Online system introduced in late 2009

ICD coding to 4 digits introduced in 2004

Birth and death forms are shared with all island facilities

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

18The geographical nature of the Maldives presents difficulty in transportation and also causes delays in timely exchange of information. However, over the years the development in telecommunication has brought about positive changes to the problem but still the problem of timely exchange of information does exist.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHAs early as 1960s births and have been reported to the Ministry of Health through a system of registration and this can be said to be the first records in a formalized manner. The previous death forms and birth forms did not flow from the atolls to Male, rather a birth and death list was compiled from atolls and sent to MoHG. MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH20Legislation pertaining to registration of births and deaths were passed and enacted in the country in 1993. The legislation entitled Registration of Births, Birth Certification and Death Certification, legislation number 7/92 was a turning point in strengthening the birth and death registration in the country.

Since its enforcement various efforts were made to improve and facilitate the process. the role of registration was passed later to Male City Councils and Island Concils in the atolls.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHEstablishment of a systematic reporting system with triplet copy method which ensures that a copy is kept at: 1) local registration facility (Male municipality and island offices 2) patient or relative and 3) Department of National Registration. It is encouraged that a photocopy of the forms are kept at the health facility.

Development of a unique serial number for each reporting form (Birth and Death) which enables tracking the reporting form and allows for follow up.

Various training workshops and awareness programmes have been conducted in the islands to familiarize with the procedure of reporting vital events.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHVarious training workshops and awareness programmes have been conducted in the islands to familiarize with the procedure of reporting vital events. Procedure Manuals have been distributed to all islands and health facilities.

Each and every field of the birth and death records are cross checked from the database with the manual reporting form.

Establishment of Online Birth and Death system.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHData processing and records maintenance at DNRAll the yellow copies of births and death forms received at DNR is entered to the computerized system. Cross checking is done to ensure the correctness of information and attempts are made to obtain any missing information on the forms

At the end of the year all the information entered to the system is checked against the yellow hard copy of the forms and validated.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH There is usually a delay in getting the forms from the atolls mainly due to lack of a monitoring. Even if staff follow up and call to request to send the forms, forms will be submitted towards the end of the year which may possible to due difficulty in transportation and sending of forms.MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTHImprovement of the yearsSince 1999 there has been a lot of work done to improve the national vital registration system of Maldives. Some of the actions that have been taken are:Establishment of a systematic reporting system with triplet copy method which ensures that a copy is kept at: 1) local registration facility (Male municipality and island offices 2) patient or relative and 3) Ministry of Health & Family. It is encouraged that a photocopy of the forms are kept at the health facility. Development of a unique serial number for each reporting form (Birth and Death) which enables tracking the reporting form and allows for follow up. Various training workshops and awareness programmes have been conducted in the islands to familiarize with the procedure of reporting vital events. MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH26Improvement of the yearsProcedure Manuals have been distributed to all islands and health facilities.

Each and every field of the birth and death records are cross checked from the database with the manual reporting form.

Establishment of Online Birth and Death system.

MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH

Thank you!MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH MINISTRY OF HEALTH