DATA EVALUATION AND METHODS RESEARCH Vital RegistrationSystemsin FiveDevelopingCountries: Honduras,Mexico,Philippines, Thailand, and Jamaica This report was prepared under the direction of the World Health Organization through a contract with the Vital Statistics Improve- ment (vISTIM) project of the Office of International Statistics, Nationid Center for Health Statistics (Contract No. BRA 230-76-0293). The Vital Statistics Improvement project is funded by the Agency for International Development through a Resources Support Service Agreement with the National Center for Health Statistics. DHHS Publication No. (PHS) 81-1353 Series 2 Number 79 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Office of Health Research, Statistics, and Technology National Center for Health Statistics Hyattsville, Md. October 1980
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DATA EVALUATION AND METHODS RESEARCH
Vital RegistrationSystemsinFive DevelopingCountries:Honduras,Mexico,Philippines,Thailand, and Jamaica
This report was prepared under the direction of the World HealthOrganization through a contract with the Vital Statistics Improve-ment (vISTIM) project of the Office of International Statistics,Nationid Center for Health Statistics (Contract No. BRA230-76-0293).
The Vital Statistics Improvement project is funded by the Agencyfor International Development through a Resources Support ServiceAgreement with the National Center for Health Statistics.
DHHS Publication No. (PHS) 81-1353
Series 2Number 79
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service
Office of Health Research, Statistics, and TechnologyNational Center for Health StatisticsHyattsville, Md. October 1980
Library of CongressCataloging in Publication DataI
Main entry under title:
Vital Registration systems in five developing countries.
(Vital and health statistics : Series 2, Data evaluation and methods research ; no. 79)(DHHS publication; no. (PHS) 81-1353)
1. Underdeveloped areas–Registers of births, etc. 2. Underdeveloped areas–Statistics, Vital. 3. Underdeveloped areas-Statistics, Medical. 4. Underdevelopedareas-Public health-Statistical services. I. Series: United States National Center forHealth Statistics. Vital and health statistics : Series 2, Data evaluation and methodsresearch ; no. 79. II. Series: United States. Dept. of Health and Human Services. DHHSpublication ; no. (PHS) 81-1353,RA409.U45 no. 79 [HA38.A1] 312’.07’23s [350’,81]
79-16799
For sale by the Superintendent of Documents, U.S. Government Printing Otlice, Washington, D.C. 20402
NATIONAL CENTER FOR HEALTH STATISTICS
DOROTHY P. PRICE, Director
ROBERT A. ISRAEL, Deputy Director
JACOB J. FELDMAN, Ph.D., Associate Director for Analysis
GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System
ROBERT A. ISRAEL, Acting Associate Director for Data Systems
ALVAN O. ZARATE, Ph.D., Acting Associate Director for International Statistics
ROBERT C. HUBER, Associate Director for Management
MONROE G. SIRKEN, Ph.D., Associate Director for Mathematical Statistics
PETER L. HURLEY, Associate Director for Operations
JAMES M. ROBEY, Ph.D., Associate Director for Pro~am Development
GEORGE A. SCHNACK, Associate Director for ResearchALICE HAYWOOD, Information Officer
OFFICE OF INTERNATIONAL STATISTICS
ALVAN O. ZARATE, Ph.D., Acting Director
Vital and Health Statistics-Series 2-No. 79
DHHS Publication No. (PHS) 81-1353Library of Congress Catalog Card Number 79-16799
PREFACE
In 1976, the National Center for HealthStatistics (NCHS) entered into an agreementwith the Agency for International Development(AID) to conduct a project directed to improv-ing civil registration and vital statistics in se-lected AID-assisted countries. The project,known as the Vital Statistics Improvement(VISTIM) project, is under the direction of theOffice of International Statistics of the NCHS.VISTIM seeks to improve the registration ofbirths and deaths, and the resulting vital statis-tics, so that the data may be used for demo-graphic analysis, population growth monitoring,health planning, family planning, and economicprogram planning and evaluation.
As a first step in the development of theVISTIM project, it was decided that studiesshould be undertaken to define the problems ofseveral countries, as a preliminary to possible de-velopment of specific assistance projects in thosecountries, and to gain an understanding of basicproblems that might be generic to civil registra-tion in the developing world. Accordingly,studies of the civd registration and vitzd statisticssystems of five developing countries were con-tracted with the Health Statistics Division of theWorld Health Organization (WHO) in Geneva.
Countries w;re selected on the basis offollowing criteria:
1. The registration of births must between 50 and 90 percent complete,
2. There should be some expectationthe system can be improved.
the
be-
;hat
3. The government ofstudied must have angram.
the country to beinterest in the pro-
On the basis of these criteria, and by mutualagreement of VISTIM, AID, and WHO; the fivecountries included in this report were selectedfor study.
The studies were conducted by teams of ex-perts assembled by the Health Statistics Divisionof WHO. In order to obtain as clear a picture aspossible of the present civil registration and vitaIstatistics system, the teams interviewed a largenumber of government officials at the nationaland at the several local levels (depending on theintemzd structure of the country being investi-gated). The team had discussions with universityand hospital authorities and population officers.Storage facilities for records were viewed. Inaddition to the five country reports, BernardBenjamin, professor of actuarial sciences of theCity of London University, has prepared a com-parative report identifying ~lommon problems.
Although the major interest of the threeagencies involved in these studies is the produc-tion of improved data, the legal ramifications ofdeficient registration systems should not be min-imized. Civil registration provides the legal basisfor proof of age, citizenship, and paternity, andthe documents are generally needed for schoolentry, employment, entry into the military orcivil service, passports, social security, andproperty inheritance. Because the need for thesedocuments occurs at various points over the life-time of an individual, deficiencies in the presenthave implications for the individual and thecountry for some 70 or 80 years into the future.
...Ill
CONTENTS
Preface ... . .. .. .. ... . ... ... .. .. .. ... .. ... .. ... .. ... .. .. .. ... . .... .. ... .. .. ... .. ... . ... .. .. ... .. ... . ... ... .. .. .. .. .. ... .. .. .. .. ................................ ..111
Chapter I. Vitaf and Health Statistics in Hondum ... ... . ... ... . .. . .. ... .. ... .. ... . .. ... .. .. .. ... . .. .. .. .. .... .. .. .. ... . .. .. 1
Chapter II. The Health and Vital Statistics Systems of Mexico .... . .. ... . ... .. .... .. . ... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. . 31
Chapter III. Civil Registration and the Collection of Vkd Statistics in the Philippines .. .. ... . ... ... ... .. .. . 55
Chapter IV. Analysis of Vital Statistics Services in Thailand .. ... .. ... . ... .. .. ... . ... .. ... .. .. .. .. ... . .. ... . .... . ... .. ... . 87
Chapter V. Vitaf Registration and the Waf Statistics Systems in Jamaica .... ... .. . .... . .... . . ... .. ... .. .. ... . ... 113
Chapter VI. Vital Registration Systems in Five Developing Countries:Honduras, Mexico, Phtippines, Thailand, and Jamaica-A Comparative Study . .. ... .. . ... 147
v
Chapter I
Vital and Health StatisticsSystemsin Honduras
Dr. Hans A. Bruch and luis Marchant Caviers
World Health Organization Study Mission to HondurasMarch 6-27, 1977
CONTENTS
Introduction .............................................................................................................................................General Infomation ............................................................................................................................ ;1972 Demographic Sumey ................................................................................ ................................... 51970-73 Improvement of Vital Statistics Project .. ...................... ......................................................... 6Health Guardians ......................................................................... ........................................................ 6No National Authority ................................................................................... ..................................... 6
Organization of the Vital and Health Statistics Systems ..... ....................................................................... 7National Level ..................................................................................................................................... 7LoCid hVcl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................... 8
Mechanisms of Registration and Certification of Vital Events ................................................................... 9Bkths ...................o..............................o....................oo........o....................o..............................o............. 9Deaths ................................................................................................................................................. 13
The Health Statistics System ..................................................................................................................... 16
Objectives ............................................................................................................................................ 16Functions ............................................................................................................................................ 16Types of Data ...................................................................................................................................... 17Organization and Stmcturc .................................................................................................................. 18Manpower Qutifimtions ................................................................................................................ ..... 18
Utilization ................................................................................................................................................. 18
Evaluation ................................................................................................................................................. 18Limitations and Defects ....................................................................................................................... 18
Education and Training Programs ............................... .................................... ................................ .......... 20Statistics Courses at the School of Medcinc .......... .............................................................................. 20Courses on Medical Records and Statistics for Auxiliary Pe~onnel ....................... ............ ........ .......... 21
Isecommendations .................................................................................................................................... 22
Appendix: Forms .............................. ....................................................................................................... 24
LIST OF FIGURES
I-1. The civil registration of births in Hondums ........................................................................................ 11
1-2. The civil registration of deaths in Honduras ................................... .................................................... 15
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CHAPTER I
VITAL AND HEALTH STATISTICS SYSTEMS IN HONDURAS
Dr. Hans A. Bruch and Luis Marchant Caviers
INTRODUCTION
General Information
Honduras, located in Central Americaj isbordered by the Caribbean Sea on the north,Nicaragua on the south, El Salvador, the PacificOcean, and Guatemala on the west. The totalarea is about 42,300 square miles. Two majormountain ranges bisect Honduras northwest tosoutheast, with tropical lowlands along bothcoastal areas. Extensive fertile valleys andplateaus lie between the mountain branches. Theclimate ranges from temperate in the moun-tainous interior to tropical in the lowlands. Thedry season extends from November to May andseriously affects the southern, western, andinterior areas of the country.
For administrative purposes Honduras is di-vided into 18 Departments. The chief officiaI ofeach Department is a Governor who is appointedby the President.
Honduras has few modern transportationand communication facilities. There are ordyabout 250 miles of paved roads. The two fruitcompanies own an additional 800 miles that areconfined to the north coastal banana region andprovide some passenger transport facilities. Rail-ways are concentrated in the banana-producingregions and serve the interests of that trade.
Air transportation is of .weat importancewithin Honduras and is frequently the normalmeans of conveyance for passengers and freight..Communication services, with the exception ofthe telegraph, are confined almost entirely tothe major cities.
i
The population of Honduras is about3,100,000 (1979 estimate). Tegucigalpa (with itssister city of Cornayaguela) is the largest city inHonduras with over 1/4million inhabitants. SanPedro Sula, principal city in the northern corn- ‘mercial heartland, has over 130,000 people.
About 90 percent of the Honduran popula-tion is a mixture of Caucasian and Indian. SmaIlminorities of Caucasians, Indians, and Blacks livethere. Spanish is the predominant language, al-though some English is spoken on the Bay Is-lands (in the Caribbean Sea) and along thenorthern coast. The literacy rate is estimated tobe about 50 percent.
The vital statistics system in Honduras hasserious shortcomings that begin at the data col-lection level. More than 40 percent of aIl deathsare never registered; fetal deaths are not regis-tered at all. Only 13 percent of the deaths thatare registered are certified by a physician. Be-cause most births occur at home (only 22 per-cent occur in maternity establishments), livebirths are under-registered by 10-12 percent.
In light of these deficiencies, any type ofanalysis to measure health conditions or changesthat occur becomes a fruitless undertaking.
1972 Demographic Survey
This situation was of such concern to theGovernment that it sponsored a demographicsurvey to measure the degree of under-registra-tion and to estimate more precisely rates ofbirth and death. This survey was performed bythe General Statistics and Census Office assisted
5
by the Latin American Demographic Center(CELADE) and the Ministry of Public Health.
There has been no exhaustive analysis of thissurvey to determine the causes and areas ofunder-registration and to propose solutions. Noactivities have been undertaken with a view toimprove coverage.
A new survey is being considered.
1970-73 Improvement of VitalStatistics Project
The General Board of Statistics and Cen-suses, with consultative help from the UnitedNations Latin American Demographic Centreand financing from the Central Bank of Hon-duras, the Higher Economic Planning Council,and the United Nations Fund for PopulationActivities (UNFPA) carried out a national demo-graphic survey of Honduras (EDENH). The mainaim of this survey was to obtain a set of reliabledemographic indexes that would enable evalua-tion of the situation with regard to the deathrate. fertilitv rate, miu-ria~erate. and mimationin Hondur&. Resultsreporting:
Vital statistics
Births .......................Deaths ......................Infant deaths ............Deaths among babies
less than 1 day old..
&licate much under-
Percent Percentreported not
reported
89.4 10.656.3 43.731.2 68.8
2.5 97.5
This Project for the Improvement of VitalStatistics, carried out between January and De-cember 1973, included:
1.
2.
3.
Program on the organization and func-tioning of a national vital statistics sys-tem.
National program for medical certifica-tion of causes of death.
Educational programs for municipal au-thorities, auxiliary mayors, hospital stat-isticians, medical records personnel, andfinal-year students in medical schools.
4.
5.
Drafting of a preliminary bill on civilregistration.
Draft decree establishing a national vitaland health statistics com-mittee.
This project did not succeed in improvingvital event coverage. Under-registration con-tinued at the same level. For a short time, therewas an improvement in the information contentand fewer data were omitted. Today, in the ab-sence of supervision or control, these problemshave again become serious.
Health Guardians
The Ministry of Public Health, recognizingthe role played by data collection in identifyingmajor health problems, now has “health guard-ians” at a few rural health centers collecting dataon births and deaths. This serves the purposes ofhealth programs, but not of civil registration.Furthermore, this program does not reach allareas of Honduras nor does it work at full ef-ficiency where it has been established.
Some of these community volunteers,trained to deliver primary health care, are re-ceiving additional training in recording the birthsand deaths that take place in their villages, ham-lets, or towns. Although there are only 300health guardians at present (1977), more than10,000 are proposed.
Plans for bringing information collected atthe rural health centers to regional and nationallevels exist. It will be important for the activitiesof the health guardians (rural) to be coordinatedwith the data collection activities of the cities toform one system that will add up to a nationalsystem of civil registration. At the moment,both sets of data are incomplete and uncoordi-nated.
No National Authority
No national authority responsible to direct,organize, supervise, or advise on the activities ofcivil registration was found. Every municipalitybehaves independently, interpreting the lawsgoverning vital registration and statistics in itsown fashion. Every municipzdity has to providethe necessary material within the limits of itsown budget. No uniform registers, no uniformentries, and no uniform information exist.
6
As to quality, no effort to setup any systemof investigation or followup to supplement theincomplete data received on births and deathswas present. It is estimated that about one-thirdof the forms submitted omit some items of in-formation (age of mother, children born pre-viously, type of care during childbirth, etc.).
Present legislation is inadequate for launch-ing a good vital statistics program. In many in-stances, those laws in force are not obeyed.
To evaluate the health situation in Hon-duras, to measure the efficiency with whichhealth resources are being used, and to judge theeffectiveness of the health and nutrition pro-grams (e.g., the impact of these programs onhealth conditions in the regions and the countryas a whole), basic data on vital and health statis-tics are required. At the moment no reliable anduseful data are available and it is merely the re-sults of the 1972 demographic survey that arebeing used. The Higher Economic PlanningCouncil collaborated with and partly financedthe 1972 survey and would like to have anotherone performed in order to determine thechanges that have occurred.
ORGANIZATION OF THE VITAL ANDHEALTH STATISTICS SYSTEMS
National Level
No ministry of the national Government ofHonduras is responsible for civil registration ofvital events. The secretaries of the 282 munici-palities of Honduras prepare weekly reports onbirths,. deaths, marriages, and divorces and sendthem to the General Board of Statistics and Cen-suses. Volunteer “health guardians” in villages,hamlets, and towns of rural Honduras reporttheir data to a municipal secretary. The GeneralBoard of Statistics and Censuses, an arm of theMinistry of the Economy, publishes a statisticalyearbook containing 21 tables of vital statistics.The issue relating to 1975 was published inJanuary 1977.
The Population and M&-ation Policy Board,which answers to the Ministry of the Interiorand Justice, intends to estabIish strict controlover the registration of births. This Board also
plans to have a departmental supervisor for eachof the 18 Departments that the 282 municipali-ties comprise. A pilot program to this end wasput into operation in April 1977.
Another important user of vital statistics isthe Higher Economic Planning Council, attachedto the presidency of the Republic as an advisorybody with power to introduce regulations. It ismade up of the ministers or secretaries of stateand representatives of industry, commerce, andlabor. The secretariat of this body is under thesupervision of an executive secretary and anexecutive undersecretary. Subordinate to theseis a technical director who has authority over 21units or sectorial offices whose purpose is toinvestigate and analyze special socioeconomicplanning sectors and coordinate their activitieswith other sectors. Among the sectorial officesare a health office and a nutrition office.
The members of the Higher EconomicPlanning Council think that it is time to convenea coordinating committee of producers and usersof vital statistics. They propose that each sectorreport the type of information it needs and theform and frequency of reporting needed. Theyare also interested in methods to improve thecoverage, quality, and timeliness of the informa-tion.
The Population and Migration Policy Boardhas a project that will require municipal secre-taries to send birth and death registration formsto the Ministry of the Interior. The Board willhave inspectors and supervisors in every Depart-ment.
The General Statistics and Census Office,neither aware of health information needs nor ofthe types of analyses that can and ought to becarried out on data of births and deaths, has notechnical personnel trained for health and vitalstatistics analysis. This Office has prepared ahandbook to help coders adjust to missing data.
The Ministry of Public Health takes no realinterest in statistical information. Althoughtechnicians interviewed pointed out the lack ofvital statistics needed to evaluate the health situ-ation and programs in the Republic of Hon-duras, not much has been done to improve the
aThe Chief of the Planning Unit, the Director of theMaternal and Child Health Department, and the Chief ofthe Epidemiological Division.
7
situation. No close and continuous communica-tion about information gaps, tabulations to aidanalysis, or problems of gathering, analyzing,and publishing the data was found. Those in theMinistry of Public Health appear well satisfiedwith the tables published annually in the Statis-tical Yearbook. Even if more detailed data be- “came available, the Ministry of Public Healthhas no professional statisticians who know howto analyze or use these data.
Local Level
The departmental political governor. -Re-porting to the Minister of the Interior andJustice, he is responsible for the municipalitiesin his department. He is appointed by the Min-ister of the Interior. As far as the civil registry isconcerned, this office should sign and stamp allthe ‘sheets in the registers used to record births,deaths, marriages, legitimation of children, rec-ognition of illegitimate children, conferment ofearly legal capacity (“emancipation”), appoint-ment of guardians, and decisions concerning sep-aration, divorce, and annulment of marriage, anddeclarations of absence and presumed death.Furthermore, a note with his signature should beplaced at the beginning and end of each registerindicating the number of sheets it contains.
In fact, the sheets in the registers are num-bered from 1 upwards; the numbering beginswith 1 again in each new register; the registersare stamped by the departmental political gover-nor’s office but not signed. The departmentalpolitical governor signs at the beginning and endof each register to certify that it contains a spec-ified number of sheets.
The department political governor has noauthority to encourage, supervise, or advise themunicipal secretaries regarding civil registration.He merely provides them with the necessaryforms or registers for carrying out their duties.In the case of the Mayor’s Office of Tegucigalpa(the municipal corporation of the Central Dis-trict ), the Minister of the Interior and Justicehimself signs the registers, since there is no de-partmental political governor.
The municipal secretary .-The secretaries ofthe municipalities are responsible for keepingcivil registers. These duties and the procedurefor civil registration are regulated by the CivilCode of 1906. The 18 Departments of the Re-
public of Honduras are subdivided into 282municipalities.
The secretaries are appointed by the mayorsof the municipalities and in general remain inoffice for a long time. The mayors are elected bypopular vote for a period of 1 year. Under thepresent Government, the mayors are appointedby the Ministry of the Interior and Justice. Evenfor cities like Tegucigalpa and San Pedro Sula(300,000 inhabitants) there is only one civilregistration office. In large towns (10,000 in-habitants or more) the municipal secretary doesnot personally keep the civil registers; one ormore municipal employees are in charge of theseactivities. Nevertheless, the municipal secretaryhas to sign all the certificates in the register.
Entries of births, marriages, the legitimationof children, the recognition of illegitimate chil-dren, the conferment of early legal capacity, theappointment of guardians, deaths, separations,divorces, and certificates of presumed deathsbare recorded in separate registers. The registershave hard covers and contain approximately200-400 pages (this number varies since eachmunicipality has to buy its own registers).
According to the law, the registers must bekept in duplicate. The original with the signa-tures of the informant and the witnesses is keptin the municipal archives. The copy, with onlythe signature of the municipal secretary con-firming the contents of the certificate, is sent tothe Central National Archives kept by the Min-istry of the Interior and Justice. Some smallmunicipfllties with scanty resources do not keepduplicate registers (Jacaleapa). Otheq municipali-ties have stopped sending these duplicate regis-ters and are in the process of copying them withthe help of extra personnel (El Paraiso). Themunicipality of Tegucigalpa does not send dupli-cate registers to the National Archives.
The Civil Code of 1906 specifies that a newregister must be used for each year; but a lateramendment (1909 ) stipulates that in view of thefact that this procedure is very expensive for themunicipalities, the registers need only bechanged when they are full. Some municipalitieswith few entries for births and deaths (less than50 a year) may take more than 5 years to fill aregister.
bNo recordiof fetaldeathsarekept.
8
Only Tegucigalpa keeps registers in whichthe entry is printed and blank spaces are left forthe relevant data to be inscribed. In other mu-nicipalities the registers consist of blank sheetsand the entries have to be written entirely byhand. There is a legal formula that the municipalsecretaries have memorized, and one entry re-quires between half and three-quarters of a page.In general, three entries can be made on everytwo pages.
Auxiliary mayors. –Within each municipality
there are auxiliary mayors for the rural area (anestimated 2,000 villages and 12,000 hamlets).These auxiliary mayors act as justices of thepeace, police authorities, and political authori-ties in the village or hamlet and are responsiblefor having the streets cleaned. They are ap-pointed by the mayor of the municipality fromamong the leading figures in the village. Accord-ing to the law, this post is compulsory and un-paid. The honorary and influential nature of thepost means that many people remain for manyyears in this position, some not fulfilling theirduties. It is estimated that 60 percent of theauxiliary mayors are illiterate. They have to ap-pear at least once a month before the mayor ofthe municipality and report on activities andevents in their villages.
Regarding civil registration, they have to re-port to the municipid secretary on the births anddeaths that occur in the village or hamlet undertheir jurisdiction. As for births, they can reportthose that have occurred, but only the father,mother, or relatives living in the house in whichthe birth occurred can have them entered in theregister. For deaths, the municipal secretary fillsin the certificate in the relevant register uponnotification by the auxiliary mayor. In practice,only very few deaths are recorded on the basisof notifications by these officials.
Hospital personnel.–At the national hos-pitals (five in the city of Tegucigalpa), the re-gional hospitals (six), and the area hospitals(seven emergency hospital centers) belonging tothe Ministry of Public Health and the two hos-pitals of the Honduran Institute of Social Secur-ity (one in Tegucigalpa and the other in SanPedro Sula), personnel are obliged to fill in thestatisticalof death)occurs in
forms of death (medical certificationand birth for every death or birth thatthe hospitrd. In practice this obligation
is not strictly met. In many cases, members ofthe family leave the hospital without asking forthe birth or death certificate. When registering abirth or death, the municipal secretary fills inthe relevant form according to the declaration ofthe informant. In other cases, the forms remainin the hands of the family as birth or death cer-tificates and are not passed on to the municipalsecretary for registration of the event. Accordingto the Regulation for the Medical Certificationof Death, the secretaries have to ask for thedeath certificate. Even if the deceased has diedwithout receiving medical care, the doctor in thehospital or health center is responsible for is-suing this certificate free of charge. Private phy-sicians also have this duty but can charge 5lempiras (about $2.50) for the certificate.
MECHANISMS OF REGISTRATIONAND CERTIFICATION OF
VITAL EVENTS
BirthsTime limit.–Registration of births is gov-
erned by the Civil Code of 1906 (Articles 304-316). The law allows a period of 8 days for regis-tration of the birth. Registration of the birth iscompletely free of charge, as is the certificate(the form provided by the General Statistics Of-fice). Some municipalities require the paymentof local and property taxes before a birth can beregistered.c
cThe authors personally observed the situation inthe municipalities of Dardi and El Paraiso in the ElParaiso Department. In the case of Danli, the impressionwas gained that the municipality will usually make acompromise in the form of partial payments of the ar-rears of taxes (usually many years) and, when theEl Paraiso the person concerned has to pay all his taxesbefore the event is registered. In the municipality ofJacaleapa no such requirement exists. After this periodand 1 year after the birth has occurred, the father, themother, or the relatives in whose house the birth tookplace, may ask for it to be recorded, subject to the pay-ment of a fine of 1-20 lempiras (504 to $10) which isfixed at the discretion of the mayor or the municipalsecretary. In practice in many cases this fine is waivedcompletely if the person concerned is very poor or, atmost, a fine of 1-6 lempiras (504 to $3.00) is levied.Whena year haselapsedsincethe dateof birththepro-cedurefor registrationhasto be carriedout before a civiljudgewith statements of witnesses.
9
Place.–The law requires that the birth mustbe registered in the municipality in which it oc-curred. When the birth occurs in a municipalityother than the mother’s residence, the municipalsecretary of that other municipality must benotified and the birth must be registered there.The municipal secretary sends a copy of the cer-tificate to the departmental politicaI governorwho then forwards a copy to the secretary ofthe municipality of the mother’s residence, sothat it can be copied in the register of births andput into the archives.
In practice,:this procedure is not followed. Ifthe mother has given” birth to a child in a hos-pital of a municipality different from her usualplace ‘of residence, she or the father will enterthe child as ~born in the municipality of resi-dence and wdl not produce the statistical formfor birth provided by the hospital. This occurs inmost cases with the knowledge of the municipalsecretary, who claims that he could not recordthe birth in accordance with the law in anyother way.
Person responsible for requesting registra-tion.–In the case of a legitimate live birth, thefather must ask for its registration. If he doesnot do this, the mother and/or relatives living inthe same house must have it registered. In prac-tice (to judge from a glance at the register For1976), it is generally the father who asks forregistration and brings with him his own and hiswife’s, identity cards.
In the case of an illegitimate child, it is up tothe mother or to the relatives living with her toask for registration. In this case, the name of thefather must be omitted. In practice it is usual forthe father to request the registration of thebirth; the mother’s name is entered, and thefather produces the identify card of the child’smother.
The law provides, furthermore, for directorsor administrators of hotels, hospitals, maternityhomes, hostels, and other similar premises to re-port to the registrar within 24 hours births oc-curring in their establishments. In practice, noneof these establishments complies with the law.Even if they did, the registrars could not domuch with the information since they cannotrecord it in the register unless the father,mother, or relatives come. However, they have
no legal authority to force the parents or theirrelatives to register the birth.
Contents of the register entry .-The law pro-vides for the following data to be included in thebirth register:
- Name and sex of the newborn child
- The day on which the birth occurred.
- The first names and surnames of the fatherand mother.
- The first names and surnames of the grand-parents.
In practice the entry recording the birth con-tains in addition the place of birth (village, ham-Iet, or town) and the age and nationality of theparents. Apparently the contents of the entryvary with each municipality and with the styleof each secretary. The statistical form for re-cording births contains, in addition, informationon the premises in which the birth took place(hospital, home, or elsewhere) and medical careif provided. (See appendix, “Forms.”)
The declaration is made. –Although the lawdoes not specify how the declaration of birthshould be made (i.e., whether it should be verbalor written), in practice the deckiration is madeby word of mouth. When the child is born in ahospital and the statistical form is filled in byhospital personnel, the recording of the birth forthe purposes of the legal entry is still by word ofmouth.
The essential requirement is that the father,the mother, or a relative living in the house inwhich the birth occurred must go in person tothe civil registration office to register the birth.The auxiliary mayor can only encourage or ad-vise the family in a village or hamlet to go to themunicipal offices and register the birth. Theauxiliary mayor cannot, as in the’ case of deaths,go to the municipal secretary to record a birth.
Witnesses.–The law stipulates that the per-son in charge of the register shall enter the birthin the register in the presence of two witnesses.He must read the entry to the witnesses and tothose concerned and they all sign it. The lawdoes not specify that the witnesses should swearthat the birth has taken place and that the per-
10
sons declaring the event are the father, mother,or relative, or that what they declare is correct.The witnesses testify that the person concernedhas given to the municipal secretary the informa-tion that is recorded in the register and that theinformation written down in the register cor-responds exactly to what th~ person concerneddeclared. In practice, in all the municipalitiesvisited, other employees of the mayor’s officesare used as witnesses. This is the general practicethroughout the Republic.
Procedure for regzktration.-In brief, the de-clarer (father, mother, or relative) presents him-self or herself before the secretary and declaresorally that a birth has taken place. The secre-tary makes an entry in the births register. Theinformant may submit his identity card if he hasone or that of the mother of the child. Once theentry has been made, the municipal secretaryreads it, the declarer signs or places a cross (if hedoes not know how to write), and two em-ployees of the mayor’s office, together with themunicipal secretary, also sign the register. Thenthe municipal secretary fills in a statistical formof birth registration, if the person concerned hasnot already brought it with him. If the personconcerned so requests (and in the majority ofcases this occurs on the secretary’s initiative),the secretary gives him/her a certificate statingthat the entry has been made and indicating thenumbers of the register and the page in the regis-ter. The form is provided free of charge by theGeneral Statistics Office. This form is not reallya birth certificate and has no legal value. Then,at the end of the day, the week, or the month,or when he has some spare time, the municipalsecretary or his employee copies the entry in theregister into the duplicate register (few munici-palkies keep a duplicate register). (See figureI-l.)
The registration ends here. It may havetaken 20-40 minutes. In the Municipal Corpora-tion of the Central District (Tegucigalpa), theprocedure does not take long because the major-ity of the informants bring the statistical formswith them. and the registers have printed entriesmeaning that the text does not have to be writ-ten out for every birth.
Birth certificate. –When a certified (legal)copy of the birth certificate is required, it must
be requested from the municipal secretary onpaper stamped with 0.50 lempira ($0.25). Ac-cording to the municipal regulation, the cost ofthe certificate is 2 lempiras ($1.00).
The law stipulates that a certificate “of thisentry” shall be issued free of charge (Article308) but does not specify its contents. The mu-nicipal secretary fulfills this requirement by is-suing a certificate that the birth has been regis-tered. This has no legal standing (see appendix,“Forms”).
Registration of illegitimate children that arerecognized. -When the father and the mother, orthe father alone (with the mother’s identitycard), goes before the municipal secretary toregister an illegitimate child, entries are made inboth the birth register and the register of recog-nitions of illegitimate children.
When the recognition is made by the fatherlater, before a judge, an entry is made, based ona document of the court certified by the judge,in the register of recognitions of illegitimatechildren; a marginal note is also made in thebirth register.
“When the act of recognition takes place in amunicipalityy different from that in which thechild’s birth is registered, the judge sends a copyof the document of the court about the recogni-tion to the appropriate departmental politicalgovernor. The Governor then sends a copy tothe municipal secretary of the municipalitywhere the child’s birth was registered, has the
I‘ Prep8r0k* stathtlcdl
Smd$ the forms wmkly
form of birthto tlm GmmlStatktlc$ Offica
I
COpim tlM entrf fromWhen th rechter is
the registerInto tha -full, 9wldsit to the
duplicate mgitterNatloml Archiws inTwcl#lP#
I
1v
Figure 1-1. The civil registration of births in Honduras
11
entry made in the register of recognitions of il- .legitimate children , and has a marginzil noteplaced in the register of births.
Registration of a newborn who dies shortlyafter birth. —Article 309 of the Civil Code saysthat the death of a newborn child does not abro-gate the obligation to record the birth. In gen-eral this obligation is not fulfilled. In some casesit is indicated that the child was stillborn (whenthe child died after a few hours or a few days).In other cases, the child is simply buried withoutany record whatsoever. It is only the “burial per-mit” that is filled in. To buy a burial permit, noproof is needed that the birth and the deathhave been recorded.
Marginal notes in regz&ers.–The law stipu-lates that on each page in the registers one-thirdof the width of the paper must be left blank fornotes on any incidents or modifications oc-curring in civil status (Article 302). These inci-dents and modifications relate to the legitima-tion of children, the recognition of illegitimatechildren, and the granting of legal capacity tosomeone under age. Although these acts are re-corded in separate registers and always consti-tute certified decisions of the court, the changesthat have occurred in civil status are entered inthe margin of the register of births, and theregister and page number on which the decisionof the court is to be found are indicated.
index to the registers of births.–The lawstates that at the end of each register (originaland duplicate ) a comprehensive alphabetical in-dex shaU be made of the entries it contains andthat sufficient pages must be left in the registerto write the index.
In practice this is done. The problem is thatin some municipalities many years may pass be-fore the register is finished and during that timethere will be no index. When someone asks for acertificate, the three municipal secretaries searchthe as yet unindexed register 2 or 3 years beforeand after the date when the person was said tohave been born or to have been registered. Inmany cases this search is laborious and time con-suming.
Late registration. –After 1 year from thedate of birth, births cannot be registered by themunicipal secretary without an order of thecourt.
To carry out late registration of a birth, theperson concerned must ask the municipal secre-tary for a certificate indicating that there is noentry for the birth in the corresponding year inthe registers of births of the municipality. Aftersearching the appropriate registers, the munici-pal secretary sends the certificate and goes be-fore the judge accompanied by a lawyer and twowitnesses. The judge notifies the district at-torney and questions the witnesses; they mustswear that they know the individual concernedand know that he was born at the place and inthe year stated. The judge has the right to askfor more evidence and may reject the testimonyof the witnesses if he is not convinced of thetruth of their declarations. Once the judge is sat-isfied by his investigations, he hands down hisdecision and orders the municipal secretary toenter the birth in the register. The municipalsecretary makes the entry by copying the de-cision of the judge and signing it together withthe person concerned.
No standard form or formula exists. Everyjudge and every municipal secretary will writeout different decisions and make entries that dif.fer slightly.
Replacement of the entry .-when an entr)in the register of births is destroyed or lost, themunicipal secretary will send a certificate onwhat has occurred to the person concerned, whothen appears before the judge with lawyers andwitnesses. As in the previous case, the judgelistens to the witnesses and their evidence andthen orders that the entry be replaced in thebirth register. The municipal secretary then en-ters the birth in the birth register of the currentyear, with the indication that this entry replacesthe entry that should have been made in theregister for the year of birth. No statistical formis prepared.
The statistical form for recording births.–The statistical form for recording births wasdrawn up by the General Statistics Office in con-sultation with the Ministry of Public Health. Itwas designed as part of the Improvement ofVital Statistics Project. M%en a child is born in ahospital, the form i: filled in by the residentphysician or the nurse. When the birth takesplace at home, the form is filled in by theregistrar at the time of registration.
12
At the Mother and Child Hospital inTegucigalpa, just after delivery, the resident phy-sician fills in the statistical form and attaches toit the clinical case history. On dkcharge, thechild and its certificate are handed over to themother. At present, the forms provided by theGeneral Statistics Office are out of print and thehospital had them reprinted in the same way.Should the child die, a death certificate is alsoissued, but in many cases these dead newbornbabies are left at the hospital by their mothers.The hospital arranges for the baby to be buriedin the town cemetery and supplies the medicalcertificate of death with the body. The birthcertificate remains with the clinical case history.Should the mother lose the statistical form sup-plied by the hospital, she is charged 1 lempira($0.50) for a copy. In this case the statisticalform is filled in by the employee of the medicalrecords department who signs it.
In practice, in many hospitals the form isnot filled in, either through negligence or be-cause the mother leaves the hospital without re-questing the document.
In some cases the mother lives in a munici-pality different from that in which the hospitalis situated. In these cases, when the mother pre-sents the form at the municipality of her resi-dence, the municipal secretary fills in anotherone indicating that the birth took place in themunicipality in which the mother lives, since thelaw requires that the birth be registered in theplace where it occurs.
In many cases, mothers keep these forms asbirth certificates and, at the time of registration,the secretary of the municipality of the mother’sresidence fills in another form.
The statistical forms are sent on Mondav of
coded as male (1) in the first case of omissionand female (2) in the next case. There are stand-ards for every omission. Also no attempt (surveyor study) is made to check the quality of theinformation, that is, to determine whether thedata recorded in the statistical form are in agree-ment with the actual facts. It is obvious thaterrors occur, for example, with the “munici-pality of birth” when a child was born in ahospital of a different municipality than that ofthe mother’s usual residence.
Deaths
Registration of deaths is regulated by theCivil Code of 1906 (Articles 337-356).
Unlike the registration of births, death regis-tration may be made ex officio upon receipt of areport or information from the police, the auxil-iary mayor, the hospitals, or the municipal secre-tary when the relatives have not made the regis-tration personally or in the case of an unclaimedbody.
Time limit.–The law stipulates that if thedeath occurs in a town or village the municipalsecretary must be notified within 24 hours. Ifthe death occurs in the country (fields, moun-tains), the auxiliary mayor must be informedwithin 24 hours (but before the body is buried)so that he can transmit the information to theperson responsible for civil registration.
In practice this is not done. Those concernedgo to the municipality to buy the burial permit,which costs 3 lempiras ($1.50) and gives permis-sion for the burial of the dead person. Later (2-3days later if they do it at all) they go to registerthe death (particularly in the case of an adult,for reasons of inheritance and other judicial or.
each week by the municipal secretaries to the administrative procedures: work, claim for socialIGeneral Statistics Office. According to the Gen-eral Statistics Office and the Office of the Cen-sus, the amount of information lacking on theseforms is immense (sex, age of the parents, areaof domicile, place of birth, medical care at birth,etc. ). There is no system of verifying the infor-mation put on the forms by municipal secre-taries or hospitals. An internal system solves theproblem. For example, if “sex” was omitted, theinformation is entered according to the person’sname. If the name does not give clues, it is
benefits, payment of taxes, etc.). No fine orpunishment is applied for such late registration(over 24 hours). Once or twice a month the hos-
pitals send the medical certificates of death forthose bodies that have not been claimed, eitherto the cemetery with the corpse for bL1ri:Llor tothe secretary of the municipality.
Place.–The law stipLdatesthat the municipalsecretary in the-place where the-dc:Lth occurredmust be notified. When the corpse has to lxtransferred to another municipality (the place of
13
residence of the deceased person), a special per-mit issued by the municipalityy is required. How-m“er, this does not ensure that the dead personrwcessarily has a death certificate or that thed.:ath was registered. It is much more a questionof administrative procedure or payment oftaxes. Usually registration takes place in the mu-i-wipality where the dead person had resided.
Person” responsible for requesting regiktra-tion.—The law says that the surviving spouse hasto report the death. Failing this, the next of kinaod after them more distant relatives must doso, In addition, the physician or surgeon whotreated the deceased and the head of the familyin whose house the death occurred are requiredto notify officials of the death.
b practice, it is the relatives who ask fordeath registration. When a dead body is notchimed from a hospital the hospital sends themedical certificate of death to the cemetery; theperson in charge of the cemetery sends it to themunicipal secretary. On the basis of these certifi-cates alone (without an informant), the secre-tmy makes an entry in the re~ster of deaths(sometimes a month after the corpse has beenburied).
The law also stipulates that any person whofinds a corpse mqst notify the municipal secre-t:lry. In practice it is the local police or munici-p~~ authorities who do so. They take responsi-bihty for making the necessary enties, carryingcwt the investigation, burying the body, and en-tering the death in the civil register.
Bun”al @emzit.–The law stipulates that themunicipal secretary shall give to i%ose concerned,f~-eeof charge, a form stating that the death wasregistered so that the manager or caretaker ofthe cemetery can have We corpse buried.Furthermore, the law stipulates ,Othatno bodymay be buried in a public or private cemeteryuntil this form has been given to the sexton ort!le caretaker.
In practice this provision is not compliedwith. This part of the law has become so con-fused and distorted that in the four municipzdi-ties visited, those concerned go to the municipal-ity to buy a burial permit which costs 3 Iempiras($1.50) (and is like a tax). They buy or rent thekind, the niche, or the mausoleum and bury thedead person without entering the death on thecivil register.
The mayors or municipal secretaries explainthis deficiency by saying that at the time thebereaved are crushed by grief and are in a hurryto bury the corpse and that this is not themoment to try to compel them to register thedeath in the civil register. They say that aftersome 3 days or more, the relatives will come andhave the entry made. Those concerned send thecertificate to the person in charge of the ceme-tery,’ who makes a list of those buried there. Inother cemeteries (i.e., municipality of Jacaleapa)there is no one in charge and no sexton. In anycase the relatives pay this tax or stamp for theburial permit and have the corpse buried. In vil-lages or hamlets where there are no municipalauthorities but only an auxiliary mayor, who isunpaid, none of these requirements is met andthere are no organized or official cemeteries.
In the Central District, the municipal secre-tary issues a certificate to the effect that theentry was made in the register of deaths, to aidin finding the register and page of the entry lateron when a death certificate is requested. Thisdocument is’ not necessary for burying thecorpse.
Information content.–The law stipulatesthat the following information shall be con-tained in the register of deaths:
The day, hour, month, year, and place of thedeath.
The given names, surname, sex, age, domi-cile, and nationality of the deceased.
The names, domicile, nationality, and occu-pation of the parents of the dead person ifknown.
The name of the surviving spouse if the de-ceased was married.
The disease or cause of death if known.
The existence or otherwise of a will.
In practice all this information is mentionedin the entry in the register of deaths. It is gen-erally observed that only the parents are men-tioned without information being given re-garding their domicile, occupation, or national-ity. There is a frequent failure to indicate thesex of the deceased. Less frequently, but it does
14
occur, the age of the deceased is omitted. In thefew cases where the relatives bring a medicaldeath certificate from a hospital, the cause ofdeath is noted in the register entry. (This occursin approximately 13 percent of all registereddeaths, most of them in Tegucigalpa and SanPedro Sula.) In the other cases, information therelatives provide is noted down.
The declamtion.-The law indicates that thedeclaration is by word of mouth (relatives go inperson to notify the municipal secretary aboutthe death). In practice, both oral and writtendeclarations are used; but in most cases they areoral. In cases where death has occurred in a hos-pital and no one has claimed the body, the bodyis sent to the cemetery together with the rele-vant medical certificate of death. From there thecertificate is sent to the municipal secretary whomakes the entry in the register of deaths on thebasis of this certificate alone. This was observedonly in Tegucigalpa. The authors were unable tofind out for certain whether it is also done inother large towns. If the body was found in thestreet, on a ‘public highway, or elsewhere in thecountry, it is the police or, in villages and ham-lets, the auxiliary mayor, who notifies the mu-nicipal secretary so that the entry can be madein the civil register. The authors were unable tosee any registration of this kind.
Witnesses.–The law does not stipulate thatwitnesses must be present for the registration ofdeaths and, in practice, they are not required.
Deaths occurring in villages or hamlets (ruralareas).–In the case of deaths that occur in ruralareas (in villages or hamlets), it is the duty of theauxiliary mayor during his compulsory monthlyvisit to the mayor of the municipalityy to reporton the situation in his village and to notify themunicipal secretary of all the deaths that haveoccurred. On the basis of this notification, thesecretary should have an entry made in the civilregister of deaths. In practice this is not done;more often the authorities wait for the relativesof the deceased to register the death when theygo to the town that is the seat of the municipalauthority. The authors did not see entries basedon a declaration from an auxiliary mayor andthe secretaries themselves admit that these auxil-iaries do not make such notifications.
Procedure for making entries.–In brief,some relative of the deceased person declares the
death. If the death has occurred in a hospital, amedical certificate of death can be obtained(this is made a compulsory requirement only bythe Municipal Corporation of the Central Dis-trict, Tegucigalpa). Even if the death has oc-curred in a hospital or if medical attention hasbeen given, it is not essential for the relatives tosubmit a medical certificate of death. The mu-nicipal secretary makes the entry in the registerof deaths. In the case of persons who have diedin a hospital and whose bodies have not beenclaimed, the secretary makes the entry in theregister of deaths on the basis of the medicalcertificate of death prepared by the hospital andsent to the cemetery (see figure I-2). The au-thors noted that only in Tegucigalpa (MunicipalCorporation of the Central District) did the mu-nicipal secretary (or the employees in charge ofthe civil register) supply the person concernedwith a certificate or form certifying that thedeath has been entered in the register and indi-cating the number of the register and the page.The only purpose served by thk certificate is to
nDeclarationby theauxiliaty mayor In tiecaseof d+athsInvill~s or hamlets(rural areat)
LtDeclarationby thn
hospital in the caM ofbcdiesnot claimedbyrelatives(medicalcertificate of death)
mhPreparesa statistical
form recordingthedeath (medicalcertificate of death]
oPreparesa certificatestatingthat the d+athhasbeenentered in theregisterof deaths
m-El
The personin charm ofthe cemetery receivesthe dmd bcdy withthe relevantdeathcertificate and sendsthe certificate to themunicipaltecmtaw
ISendsinformation
weekly to the GeneralBoardof Statisticsand Cenwtes
ITSendsthis certificate tothe personconcernedto make it easierforhim to requestadeath certificate
kEE?&.1
Figure 1-2. The civil registration of deaths in Honduras
15
make it easier later on to obtain a death certifi-cate that can be used for legal or administrativepurposes (probate, social welfare, tax questions,etc. ). When a duplicate register is kept, the entryrecording the death is copied into it. As soon asthe entry is made in the register of deaths andduly signed, the statistical form for recordingdeaths (medical certificate of death) is preparedwhenever the relative does not bring one fromthe hospital. These forms or certificates are sentweekly to the General Statistics Office.
Index to the registers of deaths.–As in thecase of births, the law stipulates that pages mustbe left free at the end of the register of deathsfor the insertion of an alphabetical index.
This is done in the municipalities, but weobserved in Jacaleapa that it takes more than 5years to fill a register. During that time, to findaq entry, the register has to be reviewed page bypage for the previous and following years.
The statistical form for recording deaths.–The medical certificate of death is in reality thestatistical form for recording deaths. This formis prepared in about 90 percent of the cases bythe municipal secretaries when they have madethe entry in the appropriate register of deaths.In the case of a de;;h ;n a hosp&l, this form isprepared in the hospital if the relative asks for it.This form, which should be compulsory in everycase has not had the anticipated impact on thesystem of vital statistics. Only the MunicipalCouncil of the Central District (Tegucigalpa) hasmade compulsory medical certification of death.
The rep”stration of fetal deaths.–The lawdoes not require the registration of stillbirthsand there is no system of legal or statisticalregistration for this type of death. The Motherand Child Hospital prepares a certificate of still-birth which was designed by the General Statis-tics and Census Office in 1970-73 during theProject for the Improvement of Vital Statistics.That is the only hospital which, to our knowl-edge, continues to use the form. The GeneralStatistics Office has stopped receiving and tabu-lating these certificates.
THE HEALTH STATISTICS SYSTEM
The Statistics Department of the Ministry ofPublic Health of Honduras is responsible to the
Planning Unit, a body that reports directly tothe Minister of Public Health.
Purpose
The main purpose of the Statistics Depart-ment is to satisfy the statistical needs of thevarious sections of the Ministry of Public Healthat their specific levels of operation and, eventu-ally, those that might arise in institutions inother national sectors and international organi-zations.
Objectives
To fulfill its purpose, the Statistics Depart-ment has established the following specific ob-jectives:
Process the statistical information generatedin the health establishments in the publicand private sector and collected periodically.
Publish this information, analyze it and dis-seminate it among the users in the sector.
Give technical advice to the other units inthe Ministry of Public Health.
Draw up technical standards for data collec-tion at the local level which will have to beapproved by higher authorities.
Supervise and coordinate the statistical activ-ities in the regions and to assist them tomeet the technical standards laid down bythe Ministry of Public Health.
Functions
The Statistics Department has the followingspecific functions:
Collect all the statistical forms filled in athealth establishments and sent through theregional statistical offices.
Ensure that these documents are received ,promptiy and regularly.
Review the forms, detect omissions, incon-sistencies, and errors, and take steps to cor-rect the deficiencies noted.
Code the information on specific forms forelectronic processing.
16
Tabulate the information manually which,by its nature, does not require the use ofelectronic or electromechanical equipment.
Punch and check cards containing informa-tion on hospital dkcharges and outpatientconsultations.
Cooperate with the Unit for the Investiga-tion and Development of AdministrativeServices by providing it with the necessaryinformation for the establishment of thesystem of supplies and costs. This involvescoding and punching cards.
Periodically send the cards mentioned to theGeneral Board of Statistics and Censuses forcomputer processing.
Solicit from the General Statistics and Cen-sus Office the “annual tabulations of hospitaldischarges and outpatient consultations pro-duced from these cards.
Ask the General Board of Statistics and Cen-suses for the special tabulations on livebirths and deaths that this organization de-velops and that the Ministry of Public Healthrequires for purposes of planning and/orevaluation of programs.
Make available to the users at the Ministry ofPublic Health all the information tabulated.
Prepare special tabulations as solicited.
Analyze the data in cooperation with theusers or independently.
Carry out a periodic evaluation of the ef-fectiveness of technical standards for statis-tical data collection and to make suggestionsfor modifications and/or expansion.
Make supervisory and/or advisory visits tothe eight administrative health regions ofHonduras.
Maintain permanent contact with theregional statisticians.
Encourage programs for training statisticalpersonnel for the various operating levelsand the various subdivisions of statistics andto take an active part inecution, and evaluation.
their planning, ex-
Prepare for the Higher Economic PlanningCouncil the information necessary for theevaluation of the programs envisaged in theoperational plan.
Estimate the quantity of forms and station-ery to be used in the establishments, and secthat they are made available and distributedpromptly.
Coordinate work with other national statis-tical organizations in matters of joint in-terest.
Represent the Ministry of Public Health inthe National Statistics Council.
Establish the system of rural health statisticsin each Centro Salud Rural (CESAR) inareas where the program for the extension ofcoverage is being implemented.
Take a direct and active part in the prepara-tion of the annual report of the Ministry ofPublic Health.
Collaborate in the establishment of the Epi-demiological Surveillance -Program and theMalnutrition Program.
Prepare the statistical information which hasto be sent periodically to internationalorganizations.
Types of Data
The Statistics Department collects the fol-lowing types of data:
Monthly report on hospital activities (finaI,intermediate, and general services).
Causes of hospitalization.
Daily report sheet for the monthly report onmedical consultations (consultations, treat-ment, preventive dentistry, immunization,population examined, environmental sanita-tion, clinical laboratory, monthly report oncommunicable diseases, and monthly reporton noncommunicable diseases).
Form for users of family planning.
Report on hospital discharges not subordi-nate to the Ministry of Public Health.
17
Form for recording tuberculosis incidence.
Forms for CESAR-community activities.
Organization and Structure
The Statistics Department is organized inworking groups that have no formal structuredue to their simple nature and small number ofofficials, some of whom perform several types ofduty.
Nevertheless. a chief and subchief level canclearly be identified, as wellpunching aqd verificationcoding, manual tabulation,forms.
Manpower Qualifications
as a group for cardand a group forand correction of
All of the 14 officials working in the Sta-tistics Department have completed secondaryschool and five of them have attended speciaIcourses ranging from a 4-month course on ad-ministration to a 10-month health statisticscourse.
In each of the eight administrative regionsthere is a statistician and all eight have attendeda 6-week course given by the Ministry of PublicHealth. Two of these officials have also attendeda 5-month course on medical records and healthstatistics.
In the hospitals, officials working on statis-tics and medical records range from people withno, statistical training to those who have studiedthe subject abroad for 1 year. Most frequentlythe course attended was a 6-week course onmedical records and statistics at Tegucigalpa.
UTILIZATION
No effective use is made of the available sta-tistical information for health activities. Re-cently, great concern about this situation hasbeen expressed by some health program man-agers who urge improving the system.
The Ministry of Public Health, the main userof the statistics of birth and death, does no an-alysis of death data in view of the high degree ofunder-registration of deaths and the poor qualityof medical certification of causes of death.
There is no mechanism for coordination be-tween users and producers of vital statistics. Nocommittee or working group has been organizedas yet. In addition, at the moment there are noreliable and useful data available and only theresults of the demographic survey of 1972 arebeing used.
The Higher Economic Planning Council col-laborated with and partly financed the demo-graphic survey of 1972 and would like anothefione to be carried out in order to determine thechanges that have occurred.
The members of this Council think that it istime to convene a coordinating committee ofproducers and users of vital statistics. They areinterested in having each sector report the typeof information it requires and the form and fre-quency of reporting needed. They are also in-terested in methods to improve the coverage,quality, and timeliness of the information.
EVALUATION
The Statistics Department of the Ministry ofPublic Health is making praiseworthy efforts toachieve the objectives stated earlier in the sec-tion of this chapter entitled “The Health Statis-tics System.”—
Limitations and Defects
Despite the constant efforts made by all re-sponsible staff, important limitations and de-fects can be found in the statistical system.These hinder the achievement of the goals setforth at the beginning of this report and havebecome a source of dissatisfaction and frequentcriticism from the users’ side. Among thesedefects, the following would appear to be themost marked:
Planning.–As part of the reformulation ofhealth policy, there is a plan for collecting statis-tical information (including the design of formsand instructions as to how they should be filledin and distributed). The remaining stages in thestatistical process have still to be defined:
Types of data needed at the various levels ofthe system.
18
Tabulation programs for each level (prepara-tion of the tables and forms of presenta-tion).
Necessary indicatom.
The utilization of the information (specificanalysis for concrete actions).
Moreover, not all the information that is col-lected is necessary and some that is necessary isnot collected.
Finally, manuals for processing the informa-tion in the Statistics Department are lacking.
Publication.-The statistical informationpublished is restricted to that contained in theannual report of the Ministry of Public Healthand the monthly epidemiological report. The re-port contains the main statistical data, region byregion, as well as indicators on resources, pro-duction, and costs for some hospitals in thecountry but not for others at a lower level.
The monthly epidemiological report is dis-tributed to all health establishments in thecountry. The annual report reaches only theregional level and the main hospitals.
Some users emphasize the disadvantages dueto the lack of continuity in the series published.
Nevertheless, the Statistics Department col-lects and analyzes additional data and statisticalseries which are not regularly distributed, butmade available on request.
Ana@’s.-The analysis that is done of theinformation processed is very limited. The Sta-tistics Department devotes the bulk of its effortsto the preparation of tables, both for publica-tion in the annual report and for other technicaldepartments. Some users carry out their ownanalyses, but these do not always reach therequired level of thoroughness nor are theycarried out with statistical expertise.
In the regions and individual establishments,this situation seems to be more acute.
Consultancy.-This is limited to meeting therequests of certain units and is not of any greatcomplexity.
Technical standards.–The Statistics Depart-ment prepares technical standards for the collec-tion and dispatch of the statistical forms, butsome other units in the Ministry occasionally
design their own forms and sets of instructions,and use channels of communication parallel tothose of the Statistics Department.
Supervision. -Supervision and advice are pro-vided at the regional level, but are sporadic andnot carried out in accordance with a preestab-lished program based on a schedule of needs andpriorities.
Defects inherent in the Department. –’I’heDepartment of Statistics lacks professiomd, tech-nical, and auxiliary staff in statistics and medicalrecords for the work of analysis, consultancy,and supervision. Also lacking are technical andauxiliary personnel in statistics and medicalrecords for the work of registration, data collec-tion, tabulation, and analysis in the regions andin health establishments. In addition, there is alack of economic resources for carrying outsupervisory and consultancy programs in thefield.
Defects inherent in the health system.–Theprogram for the extension of coverage does notinclude the whole country and in the places inwhich it is operating, the technical details forthe tabulation, analysis, and utilization of thestatistical information have not been workedout. No effective use is made of the availablestatistical information for health activities.There is a lack of close communication betweenthe technical divisions and the Department ofStatistics, which would allow the Department togain a better knowledge of the interests, needs,and justification for the statistical informationrequested by the divisions and which wouldenable the technical divisions to understand therole, knowledge, experience, and methodologythat the statistician could bring to the analysisof information.
Defects on a local level.–The mayoral of-fices carry out the work of civil registrationmore or less by tradition and because the CivilCode so orders. They do not feel that this workis very important and they do not do much toimprove the quality of the data or to encouragetotal coverage. The economic resources of manymunicipalities make it impossible for them tokeep duplicate registers or to pay a person totake charge of the cemetery. The desire torecover rates and property taxes leads somemayors to insist on payment of back taxes as a
19
condition for an entry being made (Jacaleapaand El Paraiso).
The cemeteries do not keep detailed registersof the dead buried therein and many of them donot comply with the legal obligation to send tothe municipal secretaries, once every 15 days, alist of the persons buried during that period,their given names, surname, and place of resi-dence of the deceased (Article 349, Civil Code).
The auxiliary mayor is a community volun-teer worker, illiterate in 60 percent of cases,who receives little or no encouragement to carryout his duties in regard to the civil register.
The burial permit, which in the spirit of thelaw would help to guarantee that no deceasedperson isburied without having been registered inthe civil register, was simply transformed into atax or income of the municipalities. It is notnecessary to register the death to obtain thepermit, but simply to pay 3 Iempiras ($1.50) tothe municipal treasury.
The provisions of the regulations governingthe medical certificate of cause of death are notcomplied with. Only a few hospitals have formsfor the purpose. Private physicians do not fill inthese forms. The municipal secretaries are notstrict in carrying out the”regulations, even whenthe death occurs in a hospital. ~
Fetal deaths are not recorded except by onehospital, but the information is not used.
It is essential to improve the content of theBirth and Death Certificates; the Ministry ofPublic Health may be interested in certainessential data that may be incorporated intothem.
There is little interest in investigations orsurveys by either the General Statistics Office orthe Ministry of Public Health. The demographicsurvey was promoted, conducted, processed, andanalyzed, and its results published, by CELADE.Although health or planning bodies ask forvaluable information, their interest does notseem to be strong enough to ensure the setting-aside of part of the budget for its collection andanalysis.
EDUCATION AND TRAININGPROGRAMS-
In Honduras there are only two programs forteaching vital and health statistics:
1.
2.
The statistics course at the School ofMedicine (Department of Preventive Med-icine ), Honduras Autonomous NationalUniversity.
A course on Medical Records and Statis-tics for auxiliary personnel organized bythe Ministry of Public Health.
Statistics Courses at theSchool of Medicine
In the third year of medical school, studentsare offered 30 hours of instruction that includesfoundations of statistics (rates, ratios, propor-tions, means, and averages); foundations ofdemography and epidemiology; and a descrip-tion of the health situation in Honduras.
In the fourth year another 30 hours areoffered on statistical method, probabilitytheory, main types of distribution, significancetests, sampling techniques, and the main typesof experimental design. Analysis and criticism ofscientific papers pubIished in medical reviewsand bulletins are done as part of the training.
In the fifth-year course, which is 7 weekslong, the student studies the health situation.Health programs are developed to solve theproblems encountered. Classes or meetings areheld on public health statistics, hospital statis-tics, and medical certification of death.
During the sixth year the students do prac-tical work in the communities and, many times,specific studies (tuberculosis, _rneasles,’ diarrhea,etc.). For these practical activities and studies,statistical information on the population isprepared and analyzed (the number of cases,deaths, vaccinations, etc.). The professor ofstatistics supervises and advises the students inthis practical work. The practical sessions last 6weeks. The medical school and particularly theDepartment of Preventive Medicine are quiteinterested in improving the quality and coverageof vital statistics. On some occasions, seminarswere organized for the auxiliary mayors andmunicipal secretaries about the registration ofvital events. The medical students who doPractical work in the rural communities are:instructed tosecretaries incertificates of
collaborate with the municipalthe completion of the medicaldeath. The certificates not stating
20-
cause of death are sent to the physician who,according to the symptoms at death, establishesa cause.
Courses on Medical Records andStatistics for Auxiliary Personnel
The department of medical records andstatistics is considered an essential part of everyhealth establishment.
The health care that is gken to an individualin a health establishment is recorded in theclinical history which is kept and handled in thedepartment concerned. To carry out their dutiesin a satisfactory manner, the personnel in thedepartment must receive the necessary training.
In Honduras, the staff of the departments or.services of medical records and statistics are ingeneral responsible for keeping, handling, andanalyzing clinical histories; preparing health andadministrative statistics and inpatient statistics;for maintaining case histories and other recordsin the inpatient, outpatient, and emergencyservices, and in the archives. These duties va.rYfrom establishment to establishment accordingto the degree of complexity and specializationof the establishment. and it is obvious that forthese functions, trained staff should be availableat the technical and auxiliary levels. It has beennecessary to train technical personnel in regularcourses outside Honduras since facilities for thistype of training are not available in Hondurasand the availability of this kind of personnel islow. On the other hand, it was decided thatauxiliary personnel would be trained in Hon-duras since the auxiliaries are very numerous andthe courses can be short. The national authori-ties have requested that a program be developedto continue the preparation of auxiliary per-sonnel for all of Honduras.
The program described below consists of194 hours; it is planned to use it over severalyears until the needs for auxiliary personnel aremet. The program includes material for auxil-iary personnel at different levels of medical care:It may sometimes be necessary to bring thecontent of the curricula up to date according tothe needs of the moment. The organization ofthe 1976 program is described below.
General objective.–The general objective ofthe course is to impart knowledge of medical
records and statistics to the auxiliary personnelworking in medical record or statistics depart-ments or services so that they can carry out theirrespective duties efficiently.
Specific objectives. –The specific objectivesof the course are:
To record information on admissions andregistration efficiently for each patient.
To carry out quantitative analysis of the casehistories and the coding of diagnoses andoperations.-,To keep and check clinical histories inaccordance with the established standards.
To keep archives on the basis of the termi-nal-digit method and the conventionalmethod.
To carry out efficiently the various checkson the maintenance of clinical histories.
To keep indexes of patients, diseases, andoperations.
To collect, tabulate, and present statisticalinformation daily and monthly.
In simpler types of establishment, to directand supervise’ the medical records service inaccordance with the standards laid down atthe national level.
Sponsor.–The course is sponsored by the “Hospital-School Project in cooperation with theMinistry of Public Health and Social Welfare, theHonduras Autonomous National University, andthe Pan American Sanitary Bureau.
l%rticipants.–The participants will be hos-pital and health center staff working on medicalrecords and statistics.
Duration.–The course will last 6 weeks.Theoretical and practical training will be given34 hours a week.
Requirements for admission. —To be ad-mitted to the course, the applicant must havegraduated from secondary school, attended atyping course, be at least 18 years of age, andshow an ability to deal with the public.
Syllabus. –The course for auxiliaries in medi-cal records and statistics comprises the followingsubjects:
21
Subject Hours
Administration ................................Medical records, including coding .....Mathematics .....................................Statistics...........................................Anatomy, medical terminology, and
pathology ........................................Human relationships .........................
Total ............................................
RECOMMENDATIONS
12861056
2210
196
It is urgent to implement the remainingstages in the statistical information plan as partof the program for extension of coverage. Theitems that still remain to be defined are tabula-tion programs, levels of consolidation of thedata, establishment of indexes, and the analysisand utilization of the information. Informationflows should be specified clearly and the personsresponsible for each activity .Vould also beidentified.
The extension of the statistical informationsystem should realistically include an expansionof manpower and, equipment at the local,regional, and national levels. Otherwise, theprogram proposed must be reexamined andinformation priorities defined.
It is essential for the Department of Statis-tics to play a continuous part in the existingcoordination system with a view to ensuring thatthe technical standards proposed by the depart-ment are known, discussed, and endorsed by thecoordination committee. In this way, unilateralaction by the division which is ,developingprocedures for data collection and analysis canbe avoided.
It is urgent to formulate and encourage thedevelopment of an integrated and dynamic
program for training in health statistics, in thesense that:
Continuous training and identification ofmanpower needs in order to determinetraining methods and possibilities (courses,short courses, seminars, fellowships, in-service training, etc.)
Integrated training from the departmentalhead at the central level down to theauxiliaries employed in collecting data at thelocal level. This program should also coverthe users of the information for training intechniques of data collection and analysis.
The program designed for statistical staffshould cover areas of specialization such asstatistics, medical records, systems analysis,and disease classification, according to theneeds of the health sector. In highly special-ized subjects for which no permanent staff isrequired, national or international sources ofmanpower should be identified (samplingtechniques, operations research, etc.).
The statistical information system should beperiodically evaluated and improved and thestatistical functions oriented toward the in-formation needs and the utilization of theinformation.
It is essential that the Ministry of PublicHealth take a more active role in the promotionof activities designed to improve the registrationof vital statistics and their collection, processing,and analysis.
It is necessary to coordinate these activitieswith other activities in the public sector throughthe establishment of a National Vital StatisticsCommittee or an ad hoc working group. Untilvital statistics are integrated in a satisfactoryway, the Ministry should encourage the conductof surveys that yield better estimates of demo-graphic indexes needed in health programing.
22
APPENDIX
CONTENTS
Forms.Reproduction of Statistical Report of Birth (Translated) . .... . .... .. .. .. ... .. .. . .. . ... .. .. .... . ... .. .. ... . .... .. .. . .... . .. .Reproduction of Statistical Report and Certification of Death (Translated) .. .. . .. .. .. .. .. .. .... .. . ..!...... .. .. . $Reproduction of MedicalCertification of Birth (Translated) .. .. .. .... .. .. .. ... .. ... .. .. .. .. .... .. . ... .. .... .. .. .. .. .. ... 26Reproduction of Me&cd Cetiification of Deafi(Trmdated) . ... .. .. .. .... . . .. .. .. .. ... ... .. .. .. . .. .. .. ... .. ... .. ... . ... 27Rcptoduction of Birth Certificate Receipt (Translated) . .. .. ... . .... . ... .. ... .. ... .. . .. .. .. .. .. ... .. . ... ... ... . .... . ... .. .. . 28Reproduction of Death Certificate Receipt (Translated) .. .. ... .. .. .. ... .. ... .. .. .. .. ... ... . .. . ... .. .. ... .. ... . ... .. ... .. . .. 29
.T{
Reproduction of Statistical
APPENDIX
Report of Birth (Translated)
REPUBLIC OF HONDURAS
GENEML ADMINISTRATION OF STATISTICS AND CENSUS
STATISTICAL REPORT OF BIRTH
If the biih occumed io a hospital or clinic, this report will be completed in the hospital or clinic snd given to the parents for&livery,to the Civil Registrar.
If the biih occurred without professional attention, thii report will be completed by the Registrar at the time of registration.
L Nsme of the baby:
2. Sex of the baby: Femak 3. Date of Birth:”
HI ❑ 2 Day _ Month _ Year
4a. Father’s age in completed years
— years 4b.Nationality of fiwher
5. Father’s occupation:*
6. Father’s education:University or CoIlege.,..o.o.., ❑ 1 .%ccmdsry ................. H 2
Elementary-... o..-.. ... ... ... H 3 None ... .... .. ... ... .. .... ... . H 4
7. Name of mother:
Ss. Mother’s age in completed years
yesrs 8b.Nationality of the mother
9. ISthe mother married? Yes ❑ 1 NoD2
10. Permanent address of the mother:
City or town. Village Township
11. Mother’s education:
University or College .......... ❑ 1 .%ccmdsry ................. ❑ 2
Elementary ........................ ❑ 3 None ......................... ❑ 4
12. Total number of births that the mother has had including the present b~h, whether actually she or not:
13. dild’s place of birth: 14. MO attended the mother at the birth?Ina - Ina In another Nurse Folk
Hospital house place Doctor or &lcensed) pr;~ac Other
HI ❑ 2 ❑ 3midwife person
❑ l ❑ 2 ❑ 3 ❑ 4
15, ‘lIris birth - single, twins, triplets, etc.? 16. Thii report was completed by:
Sigle Twins Triplets or more Nurse
❑ I U2 l-J3 Doctor or R@trarmidwife
Lraveblank
2.
3.
4a.
4b.
5.
6.
i’.
&.
8b.
9.
10.
11.
12.
13.
14,
15.
16.
Name of the HospitalSigoature of the person who completed the report
State Registration number
Township Registration date
*The Spanish term “trabajo Airado” is not the equivalent of occupation (ocupacic$ n),and may thus elicit answers not clmifiible as “moccupational such as worked in a factory.
24
— . . —Reproduction of Statistical Report and Certification of Death (Translated)
RBPUBLIC OF HONDURAS
GENEWiL ADMINISTRATION OF STATISTICS AND CENSUS
STATISTICAL REPORT AND CERTIFICATION OF DEATH
If the death occurred in a hospital or clinic or the deceased received professional attention, thw report will be completed by adoctor and given to the family for delivery to the CM Registry.
If the deceased did not receive professional attention (rural areas) th~ report will be completed by the Registrar at the time ofregistration.
1. Name of the deceased:
2. Date of death: Day Month Year
3, Age of the deceased in completed years:_, yearsIf the deceased is a child less than one year of age: months and days
4a, Sex of the deceased: Mde Femak 4b.
HI ❑ 2 Natiomdky of the deceased1
5. Marital status of the deceased: Single Married Widowed Divorced Consensualunion
❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5
6, Deceased’s education:University or College .......... l-Jl Secondary ..... .................. ❑ 2
Elementary ,.,,,.,,.,,..,..,, ...... ❑ 3 None ,.. .......... ................. ❑ 4
7. Deceased’s occupation*
8, CAUSE OF DEATH LENGTHla. Immediate cause ...................... Terminal sickness which directlv.
caused the deathlb. Underlying causes* *,.......,,,,.,,, Sicknesses that led to the immediate
cause I
9. The death was due to: Sickness Accident Homicide Suicide
❑ 1 ❑ 2 ❑ 3 ❑ 4
10. If the death was due to an accident at work, indicate where or for whom the deceased worked.
11. If the deceased was less than one year of age, give the following information on the mother:Age in completed years Marital StatusOccupation* tiows how to read and write
12. The death occurred in:In a Ina Irr another
Hospital house place
❑ 1 Q2 H3
13, Permanent address of the deceased:
City or town Village Township
14. This certificate was completed:In a In the
Hospittd Registrar’s office
❑ l J-J2
Leaveblank
2.
3.
4a.4b,
5.
6.
7.
8.
9.
10.
11,
13.
14.
Name of the Hospital:Siiature of the person that completed this report
State: Registration Number
Township: Registration Date
*Ths Spanish term Wrabajo realizado” is not the equivalent of occupation (ocupad6n), and may thus elicit answers not classifmble as “anoccupation;’ such as worked in a factory.
Reproductionof MadicalCertificationof Birth (Translated)
Ministry of Public Health and Social AssistanceHonduras
MEDICAL CERTIFICATION OF BIRTH
Date of birth
Sex Mu Fn
Name of the mother
&of the mother
Number of previous live birthsof the mother
Attention at Birth
Place ❑ House
Assisted by ❑ Midwife
Birth registered by:
19
❑ Other ................................ ..... ..... ................. ..(specify)
❑ Health auikry
Name
Date 19
Place
Region
❑ Health auxiliary
❑ Hospital Superintendent
I Reproduction of Medical Certification of Death (Translated)
Ministry of public Health and Social AssistanceHonduras
MEDICAL CERTIFICATION OF DEATH
Date of death
Age of the deceased*
(*in months if less than 1 year old, in years if 1 year old or older)
Sex ❑ Male ❑ Female
Residence
If the deceased is less than 1 year old, please indicate:
Age of the mother
Total number of live birthsthat the mother has had
GUSe of the death
Death Registered By:
Name
Date 19
Place
19_
months
H Assistant
❑ Hospital Superintendent
27
Reproduction of Birth Certificate Receipt (Translated)
COUNCIL OF THE CENTRAL DISTRICT
BIRTH CERTIFICATE RECEIPT
NAME OF THE NEWBORN
NAME OF THE FATHER
NAME OF THE MOTHER
DATE OF BIRTH
REGISTRATION No. VOLUME No.
YEAR
Tegyigdpa, Central District , ................ ... ...... .... ................. 197 ....(day) (month)
Secretary of the Councilof the Central ~strict
28
Reproduction of Death Certificate Receipt (Translated)
CIVIL REGISTER OF THE CENTRAL DISTRICT
DEATH CERTIFICATE RECEIPT
Name of the deceased ........ ........... .... ... ....................... ...... .......... .......... ............. ..... ......... .............. ................. ..................
.,,,,................................................................................................................................. ................................. ....................
Name of the father .... ........ .. ...... ........................ .... ............ ....... ... ........................ .... ........ .. .. ....... .............. .........................
.................................................................................................................................... ................................. ......................
Name of the mother ....... .............. ...... .. ...... ................... ........... ............ ...... ... ............................................ ........................
,!,. ,., .,,,,,,,0,,, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................... ................
Date of death ......... ........... .. .................. .............................. ............ .... .. .... .............. .......... .... ...... .............. ........................
Registration No ......... ................................. Book No ............... .... ..... ....... .. ........ .. ...... ..........
Year.............. .................. ...........................
Te~cigalpa, ............. ........ ....... .... .................... 1973(day) (month)
............................................................secretary of the Council
29
Chapter II
The Health and Vital StatisticsSystems of Mexico
Dr. Hans A. Brmch,Silvia B. Harhan, and Jo;e Louis Sanchez-lhspo
World Health Organization Study Mission to MexicoApril 18-May 6, 1977
CONTENTS
Introduction ...........................................................................................................................................General Information ...................................................................... ...................... .............O.. .............
Organization and Operation of the Vital Statistics System .............................................. ..................Organization .................................................................................................................................. .
National Level ..............................................................................................................................State and Municipal Levek .............................................. .......................... ................ ...... ............Federal District ......................................................................... ...................... ............ ............ .....
Operation ..................................................................................................... ............................ ......
Mechanisms of Registration and Certification of Vital Events .. .........................................................Births .............................................................................. .................... .... ........ .................... .........Deaths ........ ...................... ..................................................................... .......... .............. ...... ........
Organization and Operation of the Health Statistics System .................... ............. .... ........................Organization ................................................................................ .......... .............. ........ ...................
GeneAD~ctorate of Biostatistics oftie Dep@ment of Hedtiand Welfare ................... .........Office of Planning and Evaluation of the General Directorate of Coordinated Public Health
Services in the States .......................................................... .......... ................................ .............Biostatistics and Information Office, Department of Health of the Federaf District ....................Other Statistics Units in the Department of Health and Welfare
Operation................................ ..................
......................................................................... ...................................... .................. ......Deaths ............................ .................................................................... .......................... .......... .....Communicable Diseases ... ....................................................... ........................ .... .........................Human Health Resources .............................................................................................................Institutional Health Resources ........ ................................ ................ ................ .......... .. .................Morbidity of Hospital Inpatients ......................................................................... .................... ....Hospital Statistics on Bed Use .............................................................. .................... ...................Vaccination Statistics ..................................................................................................................Health Care Statistics ................................................................................ ...... .......... ...................
Evaluation ............................ ................. .................... .... ........ ...................... .............................. ........Births .................................................................................................................................... .......Deaths .............................................................. .... .............................................. .. .......................Effectiveness of Function F1 ...... .................... .......................................................... ...................Effectiveness of Function F2 ........................................ .... .......... .......................... ...... .................Heafth Statistics ...........................................................................................................................Problems Related to Education ........................... .......................................... ........................ ......
Education and Training Programs .............................................................................................. .... ...Educational Institutes ........................................................ .............................. ............ ................ ..
School of Public Health of the Department of Health and Welfare ..............................................Department of Sociaf Medicine, Preventive Medicine, and Public Health, National Autonomous
University of Mexico ....... ...................................................................... ....................................Center for Economic and Demographic Studies, El Colegio de M&xico .... ....................................Other University Institutions ............................................... .................................... .. .......... .... ....
Training Programs ... ... .......... ................................................................. ............. ............................General Directorate of Statistics, Department of Programming and Budget .......... .......................Generaf Directorate of Coordinated Public Health Services in the States .......................... ...........Office of the Chief of Preventive Medicine Services, Mexican Institute of Social Security ...........Office of the Chief of Teaching, Institute of Social Security and Services for State Workers .......
3535
363636383838
393939
404041
424243434343444444444444
45454646464747
474747
4848484949494949
33
References ............................................................................................................................. ................. 50
Appendix: Forms .......................... ....................................... ................ ................................................. 51Reproduction of Affidavit of Birth (Translated) ................................................................................. 52Reproduction of Certification of Death (TrasIated) .......................................................................... 53
34
CHAPTER II
THE HEALTH AND VITAL STATISTICSSYSTEMS OF MEXICO
Ham A. Bruch, Silvia B. Hartman, and JOS6Luis Sanchez-Crespo
INTRODUCTION
A system of health and vital statistics en-compasses functions performed by differentdata-producing institutions, users, sources ofinformation, sociocultural aspects of the society,and the type and quality of resources available.
The objectivm of the statistics system are tofurnish all levels of government and the public atlarge with relevant, reliable, coherent, and cur-rent data. These are its outputs. The inputs tothe system are primary data, models, require-ments, and priorities.
It is WCIIknown that an organization schemeis not a very accurate guide to the system inwhich actual activities, or functions, arc carriedout.
The analysis of any ~ystem moves from itsstarting point and proceeds through successivestages, defined by inputs and outputs. Eachstage must include a control function to makethe entire system harmonious, The controlfunction must b~ capable of receiving signalseither from within the system or from outsidesources, and must be able to stimulate both thesystcm itself and the surrounding cnvironmtmtthrough certain actions. Two examples of thisstimulation arc initiating requests for relevantchanges in law and influencing the choice ofbudget priorities.
The effectiveness of the function definedhere, whi~h wc will call “F1 ,“ may be measured
by how much the statistics it produces are used,their cost, and their regularity of appearance, aswell as by how many users are satisfied withthem and how important those users are.
Another function, which we shall call “F2 ,“has the mission of maintaining the framework inwhich F1 operates, in consideration of theGovernment’s long-term statistics needs. Thislong-term consideration is essential. Inevitably,there is a period between the discovery of aninformation need and the time by which it issatisfied by time series statistics.
The inputs of F2 are: the Government’slong-term plans, the signals emitted by F1 aboutthe nature and frequency of unsatisfied needs,the reliability of the statistics, the methodology,the concepts, and classifications.
The outputs of F2 are: the development andrevision of medium-term plans, new policies,concepts, classifications, and methodologies.
The effectiveness of F2 is measured by therelevance of the information provided by F1.
Although F1 may come from many differentinstitutions, F2 is the product of a central body,though its organization may be divided among anumber of institutions.
General Information
Mexico. with an area of about 761.530squareUnited
miles, is bordered on the north by” theStates of America, on the south by
35
Guatemala and Belize, on the west by thePacific Ocean, and on the east by the Gulf ofMexico. Mexico is the third largest country inLatin America (after Brazil and Argentina) andabout one-fourth the size of the continentalUnited States.
The topography of the country is varied,ranging from low desert plains and junglelikecoastal strips to high plateaus and rugged moun-tains. Beginning in southern Mexico, an ex-tension of a South American mountain rangeruns north almost to Mexico City, where itdivides to form two coastal ranges, the Occi-dental (west) and the Oriental (east) of theSierra Madre. Between these ranges lies the greatcentral plateau, a rugged tableland 1,500 mileslong and as much as 500 miles wide. From a lowdesert plain in the north, it rises to 8,000 feetabove sea level near Mexico City.
Mexico’s climate is generally more closelyrelated to altitude and rainfaIl than to latitude.Most of Mexico is dry (approximately 50 per-cent is deficient in moisture .throughout theyear) with only 12 percent receiving adequaterainfall. Temperatures range from tropical in thecoastal lowlands to cool in the higher elevations.
Mexico is composed of 29 States, the Fed-eral District, and two Federal Territories (thesouthern half of Baja California and the easternhalf of the Yucatan Peninsula). Each State isheaded by an elected Governor. Powers notexpressly vested in the Federal Government are~eserved for the States, but Mexican States’powers are much less extensive than those of theAmerican States.
By the mid-1960’s, Mexico had almost40,000 miles of paved and all-weather gravelroads. Mexico has approximately 15,000 milesof railroads; about 75 percent of this trackagehas been nationalized. Practically the wholecountry has air service. A private companyprovides virtually all of the telephone service inMexico. Telegraph service is furnished by agovernment-owned company. Radio broad-casting is extensive, and television stations doexist in Mexico City and several other cities. In1965, Mexico had 460 radio-broadcasting sta-tions, 8.3 million radio sets, 31 television sta-tions, and 1.1 million television sets. Mexico alsohas a modern postal system.
With a population of about 67,700,000,Mexico is the second most populous country inLatin America (after Brazil). More than half ofthe people live in central Mexico; however,significant internal population shifts have oc-curred since 1950. Many Mexicans have beenmigrating from areas lacking in job opportuni-ties-such as the underdeveloped southern Statesand the crowded central plateau—to the indus-trializing urban centers and the developingborder areas of the northern States. The Govern-ment has tried to reverse this trend by launchinga major development program for the south.
Almost two-thirds of the Mexicans aremestizos—mixed Indian and Spanish descent;Indian is predominant. The remainder of thepeople are primarily pure Indian, although a feware of Spanish or other European ancestry.Spanish is the official language, and over 70percent of the people are literate.
ORGANIZATION AND OPERATION OFTHE VITAL STATISTICS SYSTEM
Organization
National Level
The Federal Statistics Law assigned nationalresponsibility for vital statistics to the GeneralDirectorate of Statistics of the Department ofProgramming and Budget. Pursuant to Article382 of the Health Code, this work is done incoordination with the Department of Health andWelfare.
Among the important users of vital statistics,the General Directorate of Maternal and ChildCare and Family Planning and the NationalPopulation Council may be mentioned.
General Directorate of Statistics. —ThisDirectorate is under the Office of GeneralCoordination of the National InformationSystem of the Department of Programming andBudget. The Office of Demographic Statistics,under the Office of the Assistant Director forSociodemographic Statistics, has immediate re-sponsibility for vital statistics. The GeneralDirectorate of Statistics receives primary datafrom its offices in the States. This informa-
36
tion is included on Forms 821, 824, and 823 forbirths, fetal deaths, and deaths, respectively. Italso receives information on Forms 822 and825, for marriages and divorces, respectively.The General Directorate of Statistics edits,codes, and processes these vital statistics bycomputer and publishes them in annual publica-tions. It also sends information in the form oftabulations to the General Directorate of Biosta-tistics. By law, the data published by theGeneral Directorate of Statistics are the soleofficial records of the Mexican Republic. Thisinformation is also published in the StatisticsJournal (a monthly publication) and in somespecial studies such as “Imagen Demogr5fica, ”1“An~isis de Ios Sistemas de Informaci6n deEstadi’sticas de Natalidad y Mortalidad queoperan en Am6rica Latina 1975,”2 and manyothers.
General Directorate of Biostatistics. –ThisDirectorate is under the Office of the AssistantSecretary for Planning, a part of the Departmentof Health and Welfare. It receives vital statisticsinformation from the General Directorate ofStatistics in the form of tabulations that itreleases in an annual publication. The coverageof birth and death records varies greatly fromState to State. This coverage has not beenmeasured by any direct method. Mortality statis-tics are the basic data in many public healthprograms. They are considered valid indicatorsboth for establishing priorities and evaluatingresults.
General Directorate of Maternal and ChildCare and Family Planning.–This Directorate isin the Department of Health and Welfare. Itreceives specific instructions in matters relatedto family planning from the National ExecutiveCoordinator of Family Planning. This Director-ate relies heavily on vital statistics, mainly formaking its decisions on establishment of pro-grams. Some of its needs are not met becausethe available information is too general forapplication to the usually small areas where itconducts its programs. In addition, the systemprovides no information at all for specific areas.One example might be behavior motivation in asmall program for breast feeding as part of anoverall maternity program. This type of informa-tion may be obtained in the future by taking
sampling surveys. At this time, the Directoratehas data on tape about some 600,000 womenwho have used the family pIanning services ofthe Department of Health and Welfare. TheDirectorate does not have its own computer.
National Population Council.–The NationalPopulation Council, established by the GeneralPopulation Law of 1973, sets standards for andevaluates vital statistics collection. Its memberscome from the Departments of State and decen-tralized institutes. Its principal spheres of inter-est are family planning, maternity, education,welfare, and socioeconomic health indicators ingeneral. It has plans to conduct surveys tomeasure the impact of programs that have beencarried out in these areas.
Department of Programming and Budget.–Starting on December 1, 1976, importantchanges were made in the organic structure ofMexico’s public administration. Among thesewas the establishment of the Department ofProgramming and Budget, one of whose func-tions is to establish the foundation to coordinatethe operations of the national information sys-tem.3
To meet this responsibility, the Office ofGeneral Coordination of the National Informat-ion System was established within the Depart-ment. The following agencies were attached tothat Office:
General Directorate of Statistics of theDepartment of Industry and Commerce,
National Territory Studies Commission,
Secretary of Information for Economic andSocial Programming of the Office of theSecretary of the President.
With these resources as its foundation, theOffice of the Coordinator was structured in thefollowing way. It was given a regulatory body,called the General Directorate of Design andImplementation of the National InformationSystem.4 This Directorate was made responsiblefor designing the information policy and thedata processing to guide the actions of thenational information system, developing thetechnical standards and managing the instru~ments to coordinate the statistical work of the
37
public sector. There were also two operationalorgans, the General Directorate of Statistics andthe General Directorate of National TerritoryStudies which were assigned the task of pro-ducing the statistical and cartographic informa-tion, the basic responsibility of the Office of theCoordinator itself. Finally, it was given a sup-port organ, the General Directorate of Elec-tronic Systems and Processing, which hasresponsibility for supporting data processingactivities and general administration. Further-more, this office provides processing services tothe rest of the Department.
The basic objective of this Office is to makeall the national information services into a unitso that it can furnish reliably and promptly theinformation required for decision-making, eco-nomic and social programming, and scientificresearch, by making good use of the resourcesavailable to the Federal public sector.
The hope is to establish a system whosestandards are centralized and whose operationsare decentralized. This means that the character-istics of different sectors and regions will beused to determine their responsibilities in aspecific field of information. This field will haveto be based on previously established operatingcriteria so that its outputs are reliabIe, and canbe aggregated and integrated into .a larger sys-tem.
Following this line of action, in early 1977,the Office of the General Coordinator of theNational Information System and the Depart-ment of Health and Welfare undertook a numberof joint activities to improve data related to thehealth and social security sector. Among themost important of these joint activities were thepreparation of a basic statistics manual for theHealth and Social Security Sector, the initiationof work to unify the instructional framework ofhealth sector statistics, and a review of programsand strategies to resolve these problems.
From all this effort will come the definitionof the program to develop health and socialsecurity sector statistics, which will containspecific actions to take in the field of vitalstatistics.
State and Municipal Levels
The civil registrar’s office is the primarysource of vital statistics. The rules that apply to
recording vital statistics are included in the civillaw. Each State has its own civil code and thestandards contained in these codes do not differsubstantially from those of the Federal District’scode, although the interpretation of the defini-tion of live birth contained in the Civil Code(Article 337) could cause some confusion withfetal deaths.
Registrar’s Office. –Each town has an officeof civil re#stration. In some States, the personsresponsible for public records are, by law, themunicipal chief executive; in others they areGovernment employees, known as “registry of-ficers. ”
Statistics offices in the States. –Each Statehas a branch office of the General Directorate ofStatistics. At every branch office visited, it wasstated that the office does not have sufficientpersonnel for data gathering and supervisorywork or for secretarial duties.
Federal District
The Federal District covers an estimatedpopulation of 12 million. Until decentralizationin 1972, the Central Office constituted thearchives of the Federal District. Since then, theFederal District has been divided into 16 civilregistration zones with one or more registrarsper zone (32 public clerk offices). The personsresponsible for each of these offices are calledcivil registry magistrates. The sixth auxiliaryoffice of civil registration is responsible forcompleting the certificates of all violent deathsfor the Federal District and for all sudden deathson public ways. An unofficial certificate, whichis not forwarded to the Department of Healthand Welfare, is used for this purpose.
Operation
The input data on births that are recorded atlocal clerk offices consist of data obtained bydirect gathering (interview of the parents orguardians of the child) and, for deaths, twocopies of the death certificate submitted by therelatives of the deceased.
The outputs are Forms 821, 823, and 824(original and copy), which are sent to theGeneral Directorate of Statistics branch office inthe State; Form 6-65, original and copy, whichis sent to the State government; another copy
38
goes to the State Office of Coordinated PublicHealth Services; and another copy to the localhealth center, which also receives a copy of thedeath certificate. The vital event is recorded in abook at the office of civil registration. A copy ofthe book is sent to the superior court of justiceof the State. (See appendix, “Forms.”)
MECHANISMS OF REGISTRATIONAND CERTIFICATION OF
VITAL EVENTS
Births
The father or the mother goes to themunicipal civil registrar’s office with the new-born and two witnesses 21 years of age or older.The data for all of them are entered into twobooks that are assumed to be identical. One ofthese books is kept at the municipal office andthe other is sent to the State superior court ofjustice.
The method of entering the data into thebooks varies horn one municipaJ office toanother. Some record data in one of the books(either one) and leave the corresponding page inthe other book blank for later completion.Others take the data by voice and two personscopy them at the same time for the purpose ofavoiding errors. One difference is that somebooks are preprinted, others are not. Finally, insome municipalities there is one form for re-cording the data and then data are taken fromthis form and entered into the books.
The registration term is 15 days for thefather and 40 days for the mother. If therecording is late, a fine is charged. The amountvaries according to municipality and the amountof delay in the registration.
The fine, which is usually not less than 8pesos (about $0.35), can be suspended if theperson is poor. Some municipalities ch”arge aregistration fee of at least 31 pesos (about$1.16) even though the Civil Code states thatthis act is free of charge.
When the newborn lives only a few hours,some municipalities fill two forms, one for birthand the other for death, in accordance with theCivil Code (Article 75). However, other munici-
palities just complete the latter, that is, therecord shows a child died but not that it was
ever born. This causes a discrepancy in mortalityand birth rates.
A large percent of the recorded births arefor births in previous years. The General Direc-torate of Statistics estimates that 33 percent ofthe births registered in 1975 had occurred inprevious years. (This figure has not yet beenpublished but was provided by General Director-ate of Statistics officials. ) These late registra-tions are usually made for persons who need thebirth certificate for purposes such as socialsecurity or medical treatment.
The civil registration books provide the datafor the total number of births, without mentionof the year of occurrence and the data, areentered on Form 6-56, which should be sentduring the first 5 days of every month, bothoriginal and cop y, to the State government;another copy to the Coordinated Public HealthServices in the State; and a third copy to thepublic health center of the local area. A fourthcopy is filed.
Form 821 (data for birth statistics) is alsocompleted. The original and a copy are sent tothe local official of the General Directorate ofStatistics in the State. This form yields informa-tion on the year of occurrence and the year ofregistration of the birth.
Deaths
A Certificate of Death is an essential require-ment for recording a death and obtaining theburial permit. Nonetheless, this rule is notfollowed in some cases. The certificate is re-placed by a declaration by the judge and theforensic medical officer, a visit by a physician toview the cadaver, or by the family declaration.The certificate is submitted by the relatives ofthe deceased, and is witnessed by two persons,21 years of age or older. These persons submitto the person in charge of civil registration twocopies of the Certificate of Death. One remainsat the local civil re<gistrar’soffice and the othergoes to the health center for epidemiologicalpurposes, although apparently this dots notalways occur.
When the death certificate data are enteredinto the vital registration book, the responsibleofficers in some municipalities com.ult a physi-cian if they do not understtmd the entry (ics)
39
under causes of death. Others merely enter (inany order) the most legible causes of death.
The civil registrar’s officer completes Form823 for the General Directorate of Statistics anda copy for the Coordinated Public HealthServices in the State. In most cases, the informa-tion to complete Form 823 comes from theregistry book. The duration of the illness associ-ated with each cause of death is omitted.
If the cadaver is to be transferred to anothermunicipality for burial, a new record must bemade. This procedure could very easily result ina doubling of the actual number of such deaths.In the municipalities visited, the percent of suchrecords varied from 2 to 50 percent.
Each State statistics office should receive allinformation before the 10th day of the monthand remit it, in turn, to the General Directorateof Statistics before the 20th. In fact, it sends theinformation twice. The first instance occurs assoon as data are in from 75 percent of themunicipalities, and the second occurs as soon asthe other 25 percent becomes available.
At one of these statistics offices, it was saidthat the data are reviewed to find any grosserrors. These are confirmed and corrected bytelephone calls to the respective municipal officeof the public clerk. However, in practice, thisdoes not occur very often. The statistics officedoes not have any allotment (for travel and perdiem expenses) to visit public records offices. Ina systematic fashion, a checking procedure iskept for the registry of vital statistics by usingthe sequential numbering of the books.
ORGANIZATION AND OPERATION OFTHE HEALTH STATISTICS SYSTEM
Organization
The Mexican public health sector consists ofa great variety of governmental institutions andorganizations. These agencies, however, havedifferent degrees of autonomy and little or nocoordination exists among them. Some of theprincipal agencies are:
Department of Health and Welfare.
Mexican Institute of Social Security.
Institute of Social Security and Services forState Workers.
Medical services OE
Petr61eos Mexicanos.
State railways.
Armed Forces.
National Institute for the Protection ofChildren and the Family.
National Indian Institute.
Others.
Each of these organizations has its owndoctors’ offices and hospitals and offers pre-ventive medicine programs.
At State and municipal levels, those gover-nmentsalso have hospitals and outside consulta-tion facilities.
Efforts to coordinate health activities havebeen made through the National Committee toCoordinate Security, Health and Social WelfareActivities. This Committee operated for severalyears without much success. The Office of theAssistant Secretary for Planning has been estab-lished within the Department of Health andWelfare, with a General Coordhation Officeresponsible for promoting the coordination ofstatistical information, and other functions. Asfor the coverage of these health services, socialsecurity agencies serve approximately 35 percentof the population, especially in urban areaswhere most industrial and transport workers,and trade and government employees live.
Approximately 15 million of the rural popu-lation have only partial health service coverage.The Government and the Department of Healthand Welfare are concerned about providing thesepeople with primary health care services. Pro-grams for the extension of health service cover-age will be started soon. These programs willemploy more than 10,000 community promo-tion agents. An estimated 15 percent of thepopulation receives private medical care. Thesefigures come, through personal communications,from staff members of the social security agen-cies and the Department of Health and Welfare.
The foreRo& reveils that the health statis-tics system i; dis~ersed among a large number of
40
agencies that provide health services. Eachagency, depending on its own basic interests andits degree of complexity or sophistication, hasits own rules for recording, gathering, classi-fying, tabulating, and analyzing data on thepeople it cares for, the medical care services itdelivers, and how it uses its health resources.This fact makes it very difficult, and, in manycases, impossible, to produce national figures onhealth conditions, morbidity, services providedand health resources available.
The Department of Health and Welfare does,however, have health statistics systems andstatistics offices for special programs (e.g., ma-laria and tuberculosis) or specific geographicalareas (the Federal District, on the one hand, theStates, on the other). Each one of these systemshas its own standards for gathering, processing,and analyzing data but they are not compatible.There are no uniform national standards.
At this time, the new Government adminis-tration is reorganizing the Department of Healthand Welfare and its health statistics system. Ithas a plan to centralize and coordinate thehealth statistics system by providing it with allthe human and material resources it needs. Theplan includes resources to carry out healthsampling surveys, at both national and regionallevels. These will help to complement or supple-ment information for health proWam planningand evaluation.
The 1973 Health Code of the United Statesof Mexico provides that the Department ofHealth and Welfare will be responsible forcertain health statistics, in coordination with theGeneral Directorate of Statistics of the Depart-ment of Industry and Commerce (the Director-ate is now part of the Department of Pro-gramming and Planning). These statistics are forthe following areas:
Births, deaths, and marriages.
Illnesses and physical disabilities.
Personnel, equipment, medical units, andother resources.
Health services delivered to the public.
National health situation, by geographicarea.
Health-related ecological factors and othersubject areas that the Department of Healthand Welfare determines.
The Federal Statistics Law (Article 2) in-structs the General Directorate of Statistics tocompile statistics on facts and events in theFederal sphere of competence. Article 6 of thatLaw states that Departments of the FederalGovernment may be authorized to compilestatistics in special areas if it is done accordingto the requirements of this Law.
Mexico has two health data gathering sys-tems which operate in parallel and withoutcoordination. First, every public and privatehealth facility must report annually to theGeneral Directorate of Statistics of the Depart-ment of Programming and Budget on its activi-ties, resources, and morbidity with respect tohospital discharges (Form 933). The healthfacility must provide this report, regardless of itsparent institution or organization. Second, eachagency operates its own data system to meet itsown needs in planning, administration, andevaluation of health programs. The two datasystems involved are not compatible with eachother and use different classifications. Thusstaffs of these facilities have to maintain twoclassification systems.
The Organic Law of Public Administration,Article 32, Section III, states that the Depart-ment of Programming and Budget is responsiblefor drafting and establishing the outIines of allstatistics systems in Mexico. Article 8 of ChapterV, Internal Rules of the Department of Pro-gramming and Budget, sets forth the powers ofthe General Coordinator of the National Infor-mation System. First, the coordinator programsand coordinates the operation of the nationalinformation system and second, coordinates thecollecting and processing of data and informat-ion services.
General Directorate of Biostatistics ofthe Department of Health and Welfare
The General Directorate of Biostatistics hasjust become the main body of the Departmentof Health and Welfare health statistics system. It
41
will set the rules, advise, coordinate, and super-vise this work. Its principal function will be toestablish the national rules for collecting, proc-essing, and analyzing national health statistics.In conjunction with Department of Health andWelfare technical units, it will establish anddefine what data and how often they should begathered, and how they will be analyzed. TheGeneral Directorate of Biostatistics has fouroffices.
Processing and publications. –This office hasFederal responsibility for processing and pub-lishing data on communicable diseases, hospitaldischarges, and certain statistics about healthresources. It uses the information from theGeneral Directorate of Statistics of the Depart-ment of Programming and Budget and processand publishes information on population, births,and deaths. The latest publication prepared bythe Dkectorate of Biostatistics covering 1974data was published in 1976.5 In the future, thisoffice will process and publish all the statisticsthat the General Directorate of Biostatisticsgathers and analyzes.
Research and Statistics Advisory Serva’ces.–This new office is being organized at present. Itspurpose will be to design and conduct healthsurveys to develop rapid, reliable, and specificdata for health program planning and evaluation.Further, this office will provide technical assist-ance in statistics to all Department of Healthand Welfare technical units.
National Health Information and Documen-tation Center.–This unit is attached at the levelof a directorate. It works exclusively on findingand researching scientific documents and biblio-graphical materials on health. It is connected toforeign documentation centers by terminalhookups (MEDLAR, MEDLINE, BIREME, andothers). It works with all of Mexico’s documen-tation centers.
Demographic, Environmental, Resource, andHealth Services Statistics. -This is another newoffice that is now recruiting personnel anddeveloping an organizational structure. It will beresponsible for analyzing and preparing demo-graphic statistics (population served by watersupply and sewage systems, and other areas),statistics on health resources (human, physical,and financial), and statistics on health services.
Office of Planning and Evaluation ofthe General Directorate of CoordinatedPublic Health Sewices in the States
One part of this Office, the Office of theAssistant Director for Evaluation, is actually astatistics unit. This Office has the main functionof standardizing and organizing the statisticsoffices of the Coordinated Services in eachState. It gathers information in monthly reportsabout the activities of the health facilities(hospitals and health centers) and about specialprograms.
It keeps a current catalog of each State’shealth resources. It classifies health establish-ment “by locality and degree of sophistication(urban hospitals, rural hospitals, health centers,health houses, and others).
The Office keeps records for each State onhealth personnel by profession, hours of workcontracted, and locality.
It gathers information about vaccinationsgiven by health establishments and special vacci-nation campaigns. This information covers typesof vaccines, dosage, and age of the personvaccinated, by locality.
Taking the information it receives from theGeneral Directorate of Statistics, this Officeprepares and publishes information about births,deaths, and population for each State. It alsoprepares and publishes data covering the activi-ties of all health establishments (a recent publi-cation covers 1975).
Biostatistics and Information Office,Department of Health of theFederal District
The principal function of this Office is toprocess and prepare statistics on the activities ofthe Federal District health centers.
Using the death certificate, this Office codesthe cause of death and processes the mortalitystatistics for the Federal District. Notethat certificates are not received in cases ofviolent death or for deaths of Federal Districtresidents that occur in other States. Obviously,this is a duplication of the work performed bythe General Directorate of Statistics, but thedata We used strictly for internal purposes; the
42
official statistics of the Gener”hl’Directorate ofStatistics are released to the public.
Other Statistics Units in theDepartment of Health and Welfare
Certain programs and special campaigns havetheir own statistics units that gather, process,and publish statistics. They prepare standards,forms, and instructions which in many casesduplicate and increase the workload of the staffsof health facilities. Of these, the most importantprograms are the following:
The National Commission for the Eradica-tion of Malaria.
The National Campaign Against Tubercu-losis.
The General Bureau of Maternal-Infant Med-ical Care and Family Planning.
The National Campaign Against Cancer.
The General Bureau of Epidemiology andPublic Health Research (programs for oncho-cerciasis, pinta, rheumatic fever and others).
Operation
Deaths
The Civil Registrar’s Office sends copies ofdeath certificates to the health center in itsjurisdiction. These certificates serve strictly epi-demiological purposes. The rules state that thesecopies must be sent as promptly as possible tothe General Directorate of Biostatistics forstatistical processing. This practice has beenneglected for a considerable tim,e, but newinstructions call for starting it again. The hope isthat the activities of these offices will becoordinated so as to avoid duplicating the workof the General Directorate of Statistics.
A copy of Form 823, the Statistical Reportof Deaths, is sent by the State delegate of theGeneral Directorate of Statistics to the Office ofthe Chief of Coordinated Services in each State.This Form is used for epidemiological purposesat local, State, and national levels. Forms are notsent for State residents who die in other States
and, therefore, the data cannot be used for Statemortality statistics.
Every year the General Directorate of Statis-tics lends its detailed tabulations of births,deaths, and population to the General Director-ate of Biostatistics. This information is 2 or 3years old. Until 2 years ago, the GeneralDirectorate of Coordinated Public Health Serv-ices in the States also received tabulations onmortality, by state and municipality, from theGeneral Directorate of Statistics.
The General Directorate of Biostatistics pub-lished national and State data on the principalcauses of death by age group and sex. TheGeneral Directorate of Coordinated PublicHealth Services in the States also published Statedata on the principal causes of death by age andsex. It used to send each State a tabulation ofmortality by municipzdity, cause of death, age,and sex.
The department of health of the FederalDistrict also publishes causes of death for theFederal District. It takes these data from itsown tabulations of death certificates, which areprocessed independently of the General Di-rectorate of Statistics.
Communicable Diseases
All Department of Health and Welfare healthfacilities (hospitals, health centers, and healthhouses, as well as many facilities of the socialsecurity institutes) notify, on a weekly basis, allcases of illnesses that must be reported to theOffice of the Chief of Coordinated Services inthe States. These offices send reports to theGeneral Bureau of Epidemiology and PublicHealth Research, Department of HeaIth andWelfare, which in turn transmits the informationto the General Directorate of Biostatistics, De-partment of Health and Welfare, for processing,analysis and publication. In some States theMexican Institute of Social Security does notsend information about communicable diseasesto the Department of Health and Welfare, butpublishes this information in the Boletz% Epi-demiolbgico Mensual and the Boletin Epidemio-hgz”co Anual. When this study was being pre-pared, the report for 1977 became available.6
43
The Health Code (Article 112) lists 78illnesses that must be reported. In cases ofillnesses covered by the International HealthRegulations (cholera, yellow fever, plague, andsmallpox), and outbreaks of communicable dis-eases, the notification must be made immedi-ately, by telephone, to the State and nationallevels.
The States are now developing a new telexcommunications system. This system wouldfurnish weekly reports to the General Director-ate of Coordinated Services in the States. Casesare published in the epidemiology bulletins ofthe State, by jurisdiction. The General Director-ate of Coordinated Services in the States is alsostarting its own publication, a weekly nationalbulletin with individual State coverage.
Human Health Resources
Currently a statistics system for humanresources in the health field does not exist.Fragmentary information is available on theresources of the health institutes. The estimatesare very gross (for example, Mexico has a totalof 45,000 physicians).
Institutional Health Resources
Complete information is available about thenumber of health establishments (hospitals,health centers, and health houses), and thenumber of institutional beds. The facilities ofthe. Department of Health and Welfare areclassified by level of complexity and servicesprovided. AU information is classified by State,municipality, and locality. Information aboutthe health facilities of the social security insti-tutes and other governmental institutes is pub-lished by each institute individually and veryoften the information is old. Department ofHealth and Welfare hospitals in the FederalDistrict (the Ju&ez Hospital, Women’s Hospital,General Hospital, and others) publish yearbookscontaining data on resources, delivery of care,and death rate.
As for the health facilities of the Depart-ment of Health and Welfare, this informationcomes from the annual reports that each estab-lishment prepares. These reports are processedby the Coordinated Services in each State. TheGeneral Directorate of Coordinated Public
Health Services in the States processes theinformation at the national level and preparesthe catalogs for the individual establishments.
Morbidity of Hospital Inpatients
AU Department of Health and Welfare hos-pitals send to the General Directorate of Biosta-tistics their reports on hospital discharges. Thesereports are processed every year at the nationallevel (latest information published for 1974).5Each hospital prepares its own tabulations whichare processed at the State level.
Hospital Statistics on Bed Use
These reports provide the informationneeded to tabulate total hospital releases, aver-age stay, occupancy rate for the entire hospital,and groups of causes. The data are processed foreach hospital establishment for each State, andfor the country as a whole. Once tabulated, theinformation is published by the General Direc-torate of Biostatistics on an annual basis (latestinformation published for 1974).5
Vaccination Statistics
Health facilities prepare reports on routinevaccination programs and vaccination cam-paigns. The data are processed by health facility,jurisdiction, and State. The individual Statereports go to the General Directorate of Biosta-tistics, through the Coordinated Public HealthServices in the States, for national level proc-essing, along with information from the GeneralDirectorate of Health of the Federal District.Like the previous information, these data arepublished by the General Directorate of Biosta-tistics in Estad&ticas Vitales de 10S EstadosUnidos Mexicanos. The latest information is for1974.5
Health Care Statistics
Health facilities of the Department of Healthand Welfare prepare monthly reports on thehealth care they deliver. These reports includeinformation on care of newborns, preschoolchildren, prenatal attention, school children,dental care, home visits by health nurses, socialservices, environmental sanitation, and other
subjects, depending on how sophisticated thefacility’s services are. Each type of facility(health centers, health houses, and others) hasits own monthly report form.
This information is processed and analyzedby facility, jurisdiction, and State, by type ofhealth establishment. The General Directorate ofCoordinated Public Health Services in the Statesprocesses national information on a quarterlybasis.
EVALUATION
Certain information needs are not fullysatisfied by the types of vital statistics currentlyavailable. There are many causes for this situa-tion:
Delay in publication of statistics with re-spect to the best time that they could beused. (In April 1977 the data being usedwere for 1974. )
Large number of publications released bydifferent agencies containing statistics basedon the same raw data and showing, in somecases, serious discrepancies.
Deficiencies in channek of communication.Examples are the National Committee onVital Statistics, which has not met since itsestablishment in 1975, and the earlier Com-mittee on Demographic and Health Statis-tics, for which no information is available.
Lack of standards for analysis and use ofvital statistics by different agencies for theirown uses in forensic medicine, hospitals, andhealth centers.
Out-of-date concepts, standards, definitions,and classifications. Since 1973, only a fewisolated projects, a few of which werefinanced by the United Nations Fund forPopulation Activities, have been conductedto modernize concepts, standards, proce-dures, and definitions in the area of vitaIstatistics. Plans and programs, as well as newlaws, exist to reorganize the entire nationalinformation system.
Lack of programs to evaluate the quality andcoverage of vital statistics. At this time, the
fertiliti~ survey, which presumably will shedsome light on the quality of vital statistics, isbeing processed. Likewise, under-registrationwill be the subject of research by using thesampling design of the General Directoratefor Statistics household survey. Also, thecoverage and quality of the civil registrar’soffice of the State of Neuvo Le6n is beingevaluated at this time. This evaluation willmake it possible to estimate the under-regis-tration of births and deaths and the qualityof the vital statistics.
Births
Even though the civil codes of the States donot differ substantially from the standards forthe Federal District, insufficient training andinstructions mean that the way that they areapplied varies from one State to the next andthis has an effect on coverage. For example, theregistration rates of some municipalities, theperiod (longer than 40 days) for considering abirth registration as delayed, the amount of thefine, and the lack of a birth registration forrecently deceased newborns will all increase theomissions and have an impact on birth and deathrates. At this time, the actual number of suchomissions is unknown.
The diversity of procedures that civil regis-trars use to enter data into the books and thevarying number of transcriptions made may leadto errors, the magnitude of which also variesfrom one municipality to another.
One component that acts systematically toinflate the real number of births is the registra-tion of birth after a reasonable length of time.The amount of such registrations for the munici-palities visited could be estimated at 22 percent.Even though Form 821 can discriminate delayedbirth registrations, this is not possible on Form6-56 (whose original and four copies are sent todifferent agencies) because the latter form onlyincludes the total number of births, withoutdistinction as to year of occu~ence. The prob-lem is also not resolved by segregating birthsthat occurred in previous years. The componentof omissions for the year in question is stillunknown and depends on many causes, which inturn are different from one municipality to the
next.
45
One important factor as a generator ofduplications is the initiation of registrationcampaigns that have no adequate control mech-anism to avoid the registration of the same eventin two or more States. The activities of suchcampaigns could perhaps explain the abnormalbehavior of time series for certain phenomena,for example, the V-shaped curve of the numberof maternal deaths per 1,000 births (years1970-76).
Another aspect that should be mentionedhere concerns the lack of information about thecharacteristics and importance of vital statistics.In the pilot programs of the General Directoratefor Statistics in Morelos, Tabasco, Chiapas, andPuebla, the percent of civil registry officials whounderstood the usefulness of statistics rangedfrom 18.1 percent in Morelos to 35.4 percent inTabasco; the percent of those who understoodthe concept of live birth ranged from 8.5percent in Puebla to 91.2 percent in Chiapas.
In connection with the registry of births, wemay conclude that by eliminating the inflationcomponent due to delayed registration, theprincipal problem lies with the coverage errors(omissions and duplications) and the lack ofadequate training of the persons responsible forthe registration.
Deaths
The different criteria used by the variouspublic clerks working in civil registration officesto transfer data from the death certificate to theregistration book lower the quality of deathstatistics. Examples of these criteria are selecting(in any order) the most legible causes of death,omit ting the duration of each cause, and com-pleting, in some cases, Form 823 by using theregistration book.
Even though some omission and duplications(for example, the case of moving the cadaver forburial from one municipality to another re-sulting in a double registration) do occur,omissions and duplications for deaths are not asimportant as they are for births.
Another important aspect of errors of con-tent is the high percent of registered deaths notcertified by a physician. Their magnitude rangesfrom an estimated 71.5 percent in the State ofOaxaca to 1.7 percent in the Federal District.
According to Mexican law, Certificates of Deathand Fetal Death cannot be issued by a physicianwho is not from the same jurisdiction. Theexistence in the Federal District of four times asmany physicians per thousand inhabitants as inthe rest of the country explains the largedifference between the percents just cited.
We reach, then, the conclusion that theproblem of death registrations centers arounderrors of content.
Among the factors contributing to the poorquality of statistics are:
In filling out the death certificate, theofficial does not follow the correct order ofcauses.
Poorly defined conditions are taken advan-tage of.
Some confusion exists about the concepts oflive birth and fetal death.
There are flaws in the Certificate of Death,especially those for deaths from violent oraccidental causes.
Errors are committed in taking the datafrom the Certificate and putting them in theminute book resulting in omission of causeswhen the person who performs this opera-tion does not have a clear idea of theimportance of cause.
Errors of transcription occur in completingForm 823.
Effectiveness of Function F1
The outputs of the system for the number ofbirths are not reliab2e because the coverage isunknown; as to deaths, estimates are unreliablebecause of errors committed about causes ofdeath and, with respect to fetaJ deaths, becauseof faulty interpretations by registrars.
The outputs are not coherent; when differ-ent agencies tabulate results taken from identicalraw data, their results are different.
Finally, the outputs are not on time, as canbe seen by delays of more than 2 years.
Effectiveness of Function F2
It could be said at this time that the Fzfunction is virtually nonexistent. It is regrettable
46
,
that the National Committee on Vital Statisticshas not met since its establishment in 1975. Onthis committee are the General Directorate ofCoordinated Public Health Services in the States,the Mexican Institute of Social Security, theInstitute of Social Security and Services forState Workers, the Information System forEconomic and Social Planning, the Pan Ameri-can Health Organization, the National Popula-tion Council, and the General Directorate ofStatistics.
In addition, a decree of March, 1956 notesthe existence of a National Demographic andHealth Statistics Committee, under the Depart-ment of Health and Welfare, whose purpose wasto implement World Health Organization recom-mendations. No legal antecedents for this com-mittee have been found.
Health Statistics
The nature of the problems found in ana-lyzing the vital statistics system–lack of time-liness, duplication of effort, incomplete cover-age, low quality, absence of standards foranalysis and use, and the others mentioned-aresimilar to those found in the analysis of thehealth system. Listing them here, then, would bean unnecessary repetition.
Nonetheless, it is wise to underscore the lackof any regulatory body for the health statisticssystem. Because this system is so fragmentedamong many institutions, it must be coordinatedeffectively to avoid a multiplicity of publica-tions and to promote proper use of and demandfor statistics.
Problems Related to Education
The majority of medical professionals nowworking in Mexico have little understanding ofhow important health statistics are. Basically,this translates into careless completion of deathcertificates, medical records, and reports oncommunicable diseases.
Today’s curricula of most medical studentsin Mexico do not include health statisticscourses (the National Autonomous Universityof Mexico prepares only 35 percent of all futuredoctors in Mexico.) This means that many fu-ture professionals will have the same short-comings in this area as have their predecessors.
Staff members of civil re~stration offices donot understand the importance of their work.This is reflected in deficiencies in registration,especially of births and deaths.
The Department of Health and Welfare lackspersonnel skilled in health statistics and medicalrecords in its health facilities, State offices, andcentral offices. This is due in part to skilledpersons transferring to work at decentralized orprivate institutes that offer better pay.
EDUCATION AND TRAININGPROGRAMS
Many institutions offering courses of varyingdepth and length of training were found. Theyoffer courses to students of different academicback~ounds who work, or hope to work, inareas related to biomedical, demographic, andpublic health statistics. These institutions can bedivided into two categories: educational insti-tutes and noneducational agencies offeringcourses in statistics.
Educational Institutes
School of Public Health of theDepartment of Health and Welfare
Advanced courses. –Ten-month advancedcourses are offered for professionals holdin; amaster’s de~ee in public health or hospitaladministration who work as health programconsultants or in teaching and research. Thecourses offered are:
Advanced epidemiology.
Administration of medical care.
Public health administration.
Ten-month graduate courses are c~ffercd forthose with degrees in biomedical and socialsciences who perform executive, adviso~, andteaching research functions in public health. Thecourses offered are:
Master’s degree prosram in public health.
Master’s de,gree program in hospital adminis-tration.
47
Other specific courses for medical and ad-ministrative professionals are:
A 5-month health planning course, for staffmembers perf~rming executive and advisoryfunctions in health planning.
A 3-month health services administrationcourse, for personnel who manage localhealth services and programs.
A common objective of these seven ad-vanced courses is that the student learns to makeproper use of data such as natality, general andspecific mortality, and population projections,as well as morbidity statistics, and in turn eitherdirectly or indirectly improves the quality anduse of morbidity and health resources statisticsand employs them in project evaluation.
Other courses.–The School of Public Healthoffers a 1%-month course for professionals andhigh level technicians responsible for planningand management, and. the administration offamily planning programs. The graduates areexpected to know how to use data on natality,marriage, and infant mortality, and to producedata on the scope of programs and their effec-tiveness.
Since 1976, a 10-month undergraduate pro-gram at the bachelor level has been offered.Statistics in public health is for personnel, whowill be responsible for activities involving re-gional or national statistics related to healthservices.
Since 1955, a course for secondary schoolgraduates has been offered to more than 25students a year. Its duration has fluctuatedbetween 5 and 10 months. At this time thecourse lasts 5 months. The course, technician inapplied public health statistics, is for individwilswho will be working ivith local and regionalhealth statistics.
In addition, short field training courses ofvarying durations are offered to staff membersof health institutions.
The purpose of these courses is to enablecourse graduates to become part of a healthteam working primarily in the areas of gatheringand preparing health statistics and medicalrecords.
Department of Social Medicine,Preventive Mediciner and PublicHealth, National AutonomousUniversity of Mexico
An 18-month master’s degree program inbiostatistics is offered to university graduates(licentiates) of any profession who hope to workin advisory assistance for public heaIth agenciesand statistical analysis of data for planning,control, and evaluation; design and analysis ofhealth research; improvement of statistics sys-tems and training of technical or intermediarypersonnel in statistics. The purpose here is totrain medical and nonmedical professionals toperform executive functions in health statisticssystems and departments by offering basictraining in preventive and social medicine andpublic health prior to specializing in biostatis-tics.
A l-month special course in biostatistics isgiven once a year to medical school graduates.The purpose is to train medical professionals inmanagement and descriptive analysis of datataken from clinical and public health research.
Medical school students study 20 hours ofbasic statistics in a course entided “preventivesocial and public health medicine,” which offersconcepts about medical records, data processing,and data description.
Center for Economic andDemographic Studies,El Colegio de M4xico
A master’s degree in demography is offeredto university graduates who wish to specialize inanalysis of demographic phenomena related toprocesses of social change. It is expected thatgraduates will be able to use vital statistics andcontribute to the production of population data,especially on birth and fertility rates.
Other University Institutions
Some schools of medicine, such as Zaragozaand Guadalajara, offer a certain number of classhours (10 - 20) in health statistics as part of theirundergraduate program in medicine. Otherschools have health professionals teach suchcourses because if they are taught by engineering
48
or economics personnel, the medical studentsmight not appreciate the bearing that statisticshas on their own training. Generally speaking,most schools of medicine in Mexico offer notraining in statistics to their students.
Training Programs
General Directorate of Statistics,Department of Programmingand Budget
Training courses of varying durations areavailable to staff members of the Directorateitself, and of the Department of Health andWelfare and decentralized institutes.
A 4-month intensive course in demographyhas been offered every other year since 19T4. ““This course enables course graduates to par-ticipate in demographic evaluation and analysisand to improve the data included in integratedsystems or general or specific surveys.
A l-month course on classifications ofcauses of death in accordance with the Inter-national Classification of Diseases has been givenannually since 1974. The fundamental objectiveof this course is to train students how toidentify the basic cause of death, starting withthe death certificate, and to improve the qualityof mortality reporting.
General Directorate of CoordinatedPublic Health Sewices in the States
A 2-month course for statistical auxiliariesof Health Facilities offers in-service training to
staff members who work with medical recordsto develop communicable disease and hospitalstatistics.
Off ice of the Chief of PreventiveMedicine Services, Mexican Instituteof Social Security
This Office offers courses of varying dura-tions covering medical statistics and healthadministration for professionals employed at thedifferent health facilities of the institute. Amongthese are:
A course for newly hired epidemiologists.
A course for staff members of the Office ofthe Chief of Preventive Medicine Services.
Training for students in preventive medicineand nursing.
A 90-hour course in statistics and medicalcoding.
An 80-hour course for coders.
A 45-hour refresher course in statistics.
A course in social medicine, in coordinationwith the National Autonomous University ofMexico.
Office of the Chief of Teaching,Institute of Social security andservices for State Workers
This office offers intensive courses in statis-tics for medical research. The courses are opento resident physicians and last 1 week.
49
REFERENCES
1General Office of Statistics: Demographic picture1960-1973. Vital Statistics. Series I-No. 1. Mexico City.General Office of Statistics, Secretary of IndustryamdCommerce, Dec. 1975.
2General Office of Statistics: Analysis of the sys-tems of information of natality and mortality thatoperate in Latin America 1975. EvaIuatt”on and AnalysisSeries 111-No. 4. Mexico Chy. General Office of Statis-tics, Secretary of Industry and Commerce, Sept. 1976.
3Department of Programming and Budget: Gz&&-lines for the Implementation of the National Infomna-tion System in the Health and Soctkl Security Sector.Mexico City. Department of Programming and Budget,
Office of the General Coordinator of the NationalInformation System, Jan. 1978. Draft.
4Commu&cation from the Director. General ofDesign and Implementation of the National InformationSystem of SPP (the Department of Programming andBudget), Mexico City, Dec. 1978.
6Deptiment of Health and Social Welfare: V{tUfStatiWicsfor the UnitedStatesof Mmico 1974. MexicoCity. Department of Health and Social Welfare, GeneralDiictorate of BIOStfLtiStiCS, 1976.
6kfexican Institute of Social Security: Annual ifpi-denaidogical Report. Mexico Chy. Mexican Institute ofSocial Security, 1977.
APPENDIX
CONTENTS
FormsReproduction of Affidavit of Birth (Trmslated) ................................................................................. 52Reproduction of Medical Certification of Death (Translated) ............................................................. 53
51
APPENDIX
Reproduction of Affidavit of Birth (Translated)
No.
IN THE NAME OF THE MEXICAN REPUBLIC AND AS JUDGE OF THE CIVIL REGISTRY OF THIS
PLACE, I CERTIFY THAT IN THE VOLUME .. . . . . . . . . . . . . .. . . . . OF THE CIVIL REGISTRY, WHICH IS IN MY
CHARGE, ON PAGE .. . . . . . . . . IS TO BE FOUND AN AFFIDAVIT OF THE FOLLOWING NATURE
AFFIDAVIT OF BIRTH
:In .................................................., Federal District, at .......ltir.~ . .............. on the ,....ij~..j... of . .............. of nineteen hundred
(month)
....~.~j ........ before me .............i~.rn~j ............... .. Judge of the Civil Registry, appears .................. ...................... presenting(name of declarant)
. . . .. .. .. .. . . ... . . . . the child* .,, .. ...+............................... who wits botn at .......................... ........................ of the(Iivc or dead) (name)
. . . .. . .. .. . .. . . ... . of,,..,.,,,,(time - written out) (day) (month
. . .. .. . .. . .. . . .. . .. . . .. . . .. . . .. . .. . . .. . . an..,...,., . .. . .. . .. . .. . .. . . .. . . .. . . .. . .. . . .. . . .. . . .. . .. .. . .. . .. . . .. . . .. . .. . .. . . ... .. .. . . . .....snd year - written out) (place)
PARENTS
Names:Age:Occupation:
Nationahty:
Residence:1
PATERNAL GRANDPARENTSI
Names:
Residence: IMATERNAL GRANDPARENTS
1
Names:Residence: I
I
WITNESSES
Names:Age:Occupation:Residence:
I
The witnesses declare that ................... ............................ ....................i,., ,,,.,., ,...’ ........,..,..,,.,,..,.,..,, .............. ......,..... ...... ..........(the parent or parents)
of ................... ..... .......................... presented ........ .. of b..,.., ... .......... ............s.............. ...(child*) (srelis)
nationality and the declarant who has
his/her domicile at ....................... ........................... ...............,, ....................................................................................... ................
Havingread this affidavit they do approve and affum that they concur.
Annotations. . ................... ............................................ ........................... ..................... ...... ...................... ................................... .....
*The rex of the infant is indicated only by the word used for “child”; i.e., nifio = male child, rdiia = female child.
52
Reproduction of Medical Certification of Death (Translated)
FRONT
SECRETARIAT OF HEALTH AND WELFARE OF THESTATES OF MEXICO
MEDICAL CERTIFICATE OF DEATH
UNITED
prior to completing the certflcate read the instructions on the back.
A. DATA OF THE DECEASED.
Name.–Place and date of death.–Sex,– Age.- Marital Status,–
Nationality.– Habitual occupation.–Habitual Residence.–Father’s name Living?Mother’s name Living?
Spouse’s name Living?
B. DATA OF THE DEATH:
place, date and hour occurred:
CAUSES Approximate interval, between the onset of
I Ithe sic~ess ad cleat]
Sickness or other cause directly producing the death (a) I
Sickness or other cause underlying the direct cause (b) IOther previous pathological conditions related to the (c)sickness producing death I
H I
Other pathological conditions that were Inot related to the principal or basic sickness I
C. DATA ON THE DEATH FROM VIOLENT OR ACCIDENTAL CAUSES
place, date and hour in which occurredSuicideHomicideAccidentDid it occur during a work situation?
D. DATA ON THE CERTIFYING DOCTOR
NameHealth and Welfare Secretariat registration numberDepartment of Professions I.D. card numberResidence and telephone numberDid the certifying doctor attend the deceased during the last illness?Place and date certifiedSignature of certifying doctor
E, DATA ON THE DECLARANT GIVING NON-MEDICAL INFORMATION
Name
Residence
Signature or finger prints
Chapter Ill
Civil Registration and theCollection of Vital Statisticsin the Philippines
Dr. Joan Lingner, Adriaaa C. Regudo, and Dr. Alain Vessereau
World Health Organization Study Mission to the PhilippinesFebruary 21-March 13, 1977
CONTENTS
Introduction ............................................................................................................................................. 59Gcnerd Information ............................................................................................................................ 59Mstoricfl Bac&ound ......................................................................................................................... 60
Or@nization ............................................................................................................................................. 62National hvel ..................................................................................................................................... 62Locaf Level ........................................................................................................................... ............... 63
Registration ..............................................................................................................................................Forms for Registration and Certification ............................i................................................................
Witnesses .............................................................................................................................................Delayed Registration ...........................................................................................................................Fees for Registration of Events ....... .............................................. ....................................................Certified Copies ..................................................... ..............................................................................Burial Petits ......................................................................................................................................Special Problems ..................................................................................................................................Locaf Registers ....................................................................................................................................Local CM Registrar ............................................................................................................................Vital Records .......................................................................................................................................
646465666667676868697172
Utifimtion of Statistics Denvedfiom tie~til Re@stmtion System ........................................................ 74Depmtment of Hedfi.;.{ ...................................................................................... ................ ............... 74Poptiation Projections ......................................................................................................................... 75
Utilization oftiti Re@st~Records ......................................................................................................... 76Certificate of Live Birth ...................................................................................................................... 76Certificate of Death ............................................................................................................................. 76Certificate of Fetaf Death or Stillbirth ....................................................................................... .......... 76Marriage Contract ................................................................................................................................ 76
Ev&uation ................................................................................................................................................. 77Re@stmtion Completeness ........... ........................................................................................................ 77Assessment of Vlti Rates .................................................................................................................... 77The POPCOM/NCSO Project ........................................... ................ .................................................... 77Cause-of-Death Statistics ................................................................. .................................................... 78Factors of Underregistration ............... ................................................................................................ 78
Remedies of Underregistration ................................................................................................................. 79.
The Administration ............................................................................................................................. 79LOcaf Level ..................................................................................................................................... ..... 79population kveI .................................................................................................................... .............. 80
References ................................................................................................................................................ 80
Appendix: Fores ..................................................................................................................................... 81
9
57
CHAPTER Ill
CIVIL REGISTRATIONAND THE COLLECTIONI VITAL STATISTICS IN THE PHILIPPINES
Dr. Joan Lingner, Adriana C. Regudo, and Dr. Alain Vessereau
INTRODUCTION
General Information
The Philippine Islands, consisting of about1,100 islands and islets, extend about 1,100miles north to south along the southeastern rimof Asia. The Philippines are scpatated from theRepublic of Chini- (Taiwan) on the north andMalaysia and Indonesia o,n the south by straits afew miles wide and from Vi@-Nam and main-land China on the west by the 600-mile breadthof the South China Sea. The total land area isabout 115,707 square miles. Quezon City, nearManila, was declared the capital in 1948, butmost govcrnmtmt activities remain in Manila.
The Philippine Islands lie within the tropics.T.hc lowland areas have a year-round warm andhumid climate with only slight variations in theaverage mean temperature of 80° F. Rainfall isgenerally adequate, but varies from place toplace bccausc of wind directions and the shield-ing effects of the mountains, The average annualrainfall in Manila is 82 inches, The wet season inthe Manila area begins in June and ends in No-vember. The country lies astride the typhoonbelt and an averam if 15 of these storms hit thePhilippines annu~ly. A number of active vol-canoes exist, and the islands arc subject to de-structive earthquakes.
In the Iatc 1960’s about 40,000 miles ofroads existed, about half of them were first-
grade. The railways, of the narrow-gauge type,tie over 700 miles in length. More th-m 240,000telephones were in use in the late 1960’s; ofthese, about 60 percent were in Manila. Tele-grams usually replace long-distance telephonecalls. The islands have a network of 160 radioand 7 television stations. In 1965, 1.5 millionradio sets and nearly 100,000 television setswere in operation. Local interiskmd trade tomore than 200 ports is handled by over 6,000vessels.
The population of the Philippines is about46.2 million (1979 estimate). Manila has over 3million and Quezon City has over Y2 millionpeople.
The population is predomin~tly of Malaystock, descended from Indonesians and Malayswho migrated to the islands centuries ‘ago. Themost significant alien ethnic group is theChinese, who have played an import~t role incommerce at least since the ninth centtu-y whenthey first came to the islands to trade, As a re-sult of intermarriage, many Filipinos have partialChinese ancestry. Americans and Spaniards con-stitute the next largest alien minorities.
Eighty-seven native languages and dialects,all belonging to the Malayo-Polynesian linguisticfamily, are spoken, but eight of these are themother tongue of more than 86 percent of the
‘population. Filipino, English, and Spanish arethe official languages. Since 1939, in an effortto develop national unity, the Government has
59
promoted the use of the national language–Filipino. Filipino is taught in all schools and is... .... . .gammg increasing acceptance, particularly as asecond language. English, the most importantnon-native language in the Philippines, is used asa second language by about 40 percent of thepopulation and is the universal language of pro-fessional people, education, and government.Spanish is spoken by less than one millionpeople, largely of the social elite, and its useappears to be decreasing. Despite the multiplic-ity of languages, the Filipinos have one of thehighest literacy rates in the East Asian andPacific areas.
Historical Background
The earliest systematic recording of birthsand deaths in the Philippines was that in churchregisters of baptisms, marriages, and burials.l%ese records, which were required by theCatholic Church, have largely disappeared ex-cept for the period 1876-98. Although geo-graphic coverage of the registers is fragmentary,birth reporting within the areas for whichrecords exist must have been rather complete .judging from the relatively high birth rates thathave been estimated from these data. Birth ratesranged from 51.7 per thousand population(1887) to 43.2 in 1890 and death rates from58.2 in 1889 to 26.2 in 1887.
Civil registration was briefly established in1889 when the Civil Code of Spain was effectu-ated in the Philippines, only to be rescindedwithin a month by order of the Governor-General.
“However, at about the same time, theCentr6 Estadistica (Central Office of Statis-tics) was created as a dependency-of the Di-reccfon General de Administracfon Civil(Bureau of Civil Administration). Under thisnew setup, the parish priests were requiredto send to the Central Office of Statistics inManila, a detailed statement of the births,marriages, and deaths that had occurred intheir respective parishes during the year im-mediately preceding their reports. Regis-tration of births included the name and sexof the child and the place of birth. The mar-
riage register covered the full names of thecontracting parties, their ages, sexes, races,and birthplaces, and any remarks pertinentto the information given. Death records indi-cated the name, age, sex, and place of birthof the decedent. Thus, the organization ofthis Central Office of Statistics marked thebeginning of the scientific treatment of vitalstatistics in the Philippines. ” (p. 11)
The first central statistics office was staffedby one chief, one chief clerk, and three assist-ants.
Beginning in 1898, a decree of the revolu-tionary government established a completelysecularized civil registration system in townsunder the control of the independent govern-ment. “Vital events were then registered underthe Office of the Justice and Civil Registration.The Chief of this office was assisted by anelected delegate of the people, who in turn pre-pared the record book of births, deaths and mar-riages and the census. ” (p. 1592 ) During the eraof American colonial government, the PhilippineCommission’s Act. No. 82 (1901) provided thateach municipal secretary maintain civil registers.The Bureau of Archives, also created in 1901,was given “care and custody” of certain publicrecords. In 1922, the Bureau of Archives wasincorporated as a division of the NationalLibrary (Act No. 3022). At that time, municipalsecretaries were required to submit quarterly re-ports on registration matters to the Chief of theDivision of Archives. These regulations markedthe beginning of centralization of civil registra-tion. The 1930 Civil Registry Law (Act No.3753 ), which continues in force as the basis forcivil registration, orginally named the Directorof the National Library as Civil Registrar-General, although this has since been amended.
The Bureau of Census and Statistics wascreated by Commonwealth Act No. 591 in1940. The functions of the Division of Archives(National Library) and of the Vital StatisticsSection (Bureau of Health) were transferred tothe Bureau of Statistics, now known as theNational Census and Statistics Office. At pres-ent, the Executive Director of the National Cen-sus and Statistics Office is ex-officio Civil
&l
Registrar-General. Outside of chartered cities’local civil registrars are the municipal treasurers,who are civil service employees responsible tothe Department of Finance, or their duly ap-pointed assistants. Within chartered cities, cityhealth officers or city secretaries serve in thiscapacity. Both groups of officials serve the civilregistry in an ex-officio capacity, without extracompensation for the addition to their ordinaryduties.
Until 1974, the Department of Health alsocollected information on natalit y and mortality,as well as morbidity, through the national net-work of city and municipal health officers. Inrecent years, however, the National Census andStatistics Office has assumed exclusive responsi-bility for the collection of birth and death statis-tics; analysis of these data, as well as collectionof morbidity data and other types of morbiditystudies, continues to be a responsibility of theDepartment of Health.
The legal basis for civil rep>tration.–As pre-viously noted, the 1930 Civil Registry Law (ActNo. 3753 ) continues in force as the basic legisla-tion pertaining to civil registration. This law liststhe types of events and changes in status whichare to be included in the civil registers; specifiesthe information to be collected about eachevent; and designates responsibilities for declara-tions, registrations, and certificates. The CivilRegistry Law also contains provisions for feesfor registration and for copies of certificates andfor penalties for violation of the Act.
The general provisions of the Civil RegistryLaw are reiterated in the New Civil Code of the
\a“Cities” are corporate political bodies endowed
with the attributes of perpetual succession and possessedwith powers which pertain to municipal corporation tobe exercised by them in conformity with the provisionsof their respective charter. Each city, unlike municipali-ties which are created under a general law, is created bya special law known as the city’s charter passed by theNational Assembly.
As of 197.3, there were 61 chartered cities in thePhilippines (pp. 57-621 ).
b“Municipalities” are subdivisions of provinces.These units of local government are political ‘corporatebodies and as such they are endowed with the facultiesof municipal corporations. The municipal treasureris ap-pointed by the provincial treasurer.
Philippines. Book I, Title III of the Code speci-fies the laws pertaining to marriage, includingissuance of marriage licenses, authority to solem-nize marriages, and registration of marriage con-tracts.
More recently (1975) Presidential DecreesNo. 651 and No. 766 were issued. These decreeswere intended to strengthen existing laws onregistration of births and deaths.
Essential features of these decrees are:
The compulsory registration of births anddeaths that occurred from January 1, 1974and thereafter.
The requirement for proof of birth registra-tion as a prerequisite for school enrollmentand allowance of tax exemption for depend-ents under the National Internal RevenueCode.
The responsibility of barrioc captain andbarangayd chairman for assisting in the regis-tration of births and deaths. Presidential De-cree No. 651 specifically provides for theregistration of all births and deaths occurringafter January 1, 1974, within a period of 60days after the date it became effective. Thkreporting period, extended by PresidentialDecree No. 766 to December 31, 1975, hassubsequently been extended to December31, 1977.
The legislation concerning civil registrationand vital statistics has been reinforced andamplified by a series of implementing rules andregulations (Administrative Order No. 1/1975and Administrative Order No. 2/1975).
The Civil Registry Law’s penal provisionsstate also that failure to report any event that
CJ4B~&” are units of the municipalities or munici-pal districts in which they are situated. They are quasi-municipal corporations endowed with such powers as arenecessary for the performance of particular governme-ntalfunctions. The barrio captain is elected at a meetingof the barrio assembly.
d’%a.mngays” are the citizen assemblies in barrios,city districts, and wards. They are now the instrumental-ities from which statistics and announcements arecoursed through. Thirty-five thousand barangays havebeen organized.
61
affects the status of a person is punishable underthe law. Any person who shall knowingly fail toreport or who makes a false statement in thepreparation of certificates presented for registra-tion in the civil registers shall be meted out thecorresponding punishment for such acts.
ORGANIZATION
National Level
As noted previously, the Civil Registrar-General is an ex-officio position of the Execu-tive Director of the National Census and Statis-tics Office. The Director also serves as DeputyDirector General of the National Economic andDevelopment Authority for the Statistical Co-ordination Office.
The Statistical Advisory Board, the com-mittee charged with the responsiblity for recom-mending statistical policy, is also attached to theNational Economic and Development Authority.This Board which is chaired by the Director ofthe National Census and Statistics Office co-ordinates the activities of 18 interagency com-mittees for coordination of statistical activities inspecific areas. Formerly, vital statistics fell in theprovince of the Interagency Committee onHealth and Social Service. However, because theNational Census and Statistics Office presentlyhas sole authority to collect vital statistics data,and because vital records and statistics have im-plications broader than health and social serv-ices, it appears likely that one of the other inter-agency committees, possibly that of populationand housing, will assume responsibility for vitalstatistics in the future.
Responsibilities -of the Civil Regi>tra&Gen- ,eral.–The duties and responsibilities of the CivilRegistrar-General are embodied in the CivilRegistry Law (Act No. 3753) of 1930 as fol-lows:
“SECTION 2. Civil Registrar-General: Hisduties and Powers–The Director of the Na-tional Library shall be Civil Registrar-Gen-eral and shall enforce the provisions of thisAct. The Director of the National Library, inhis capacity as Civil Registrar-General, ishereby authorized to prepare and issue, withapproval of the Secretary of Justice, regula-tions for carrying out the purposes of this
Act, and to prepare and order printed thenecessary forms for its proper compliance.In the exercise of his functions as CivilRegistrar-General, the Director of the Na-tional Library shall have the power to giveorders and instructions to the local civilregistrars with reference to the performanceof their duties as such. It shall be the duty ofthe Director of the National Library to re-port any violation of the provisions of thisAct and all irregularities, negligence or in-competency on the part of the officers designated as local civil registrars to the (Chief ofthe Executive Bureau or the Director of theNon-Christian Tribes) Secretary of the In-terior, as the case may be, who shall take theproper disciplinary action against the of-fenders.”
As previously noted, the Office of the CivilRegistrar-General was subsequently transferredto the Director of the Bureau of the Census andStatistics and presently to the Executive Direc-tor of the National Census and Statistics Office.
Responsibility for the compilation andanalysis of the data from the civil registrars andfor the production of vital statistics and othertypes of analysis does not seem to have an ex-plicit basis in law, but rather appears to fallwithin the general provisions of CommonwealthAct No. 591 which directs the Bureau of theCensus and Statistics to “compile and classify allsuch statistical data and information and to pub-lish the same for the use of the Government andthe people.” At present, there appears to be aworking agreement between the National Censusand Statistical Office and the Department ofHealth such that the National Census and Statis-tical Office compiles, tabulates, and publishesthe raw data from the civil registration system,and further analyses, including rate calculation,are carried out by the Department of Health.
The Civil Regi>try and Vital Statistics Di-vision of the National Census and Statistical Of-flee.-The Civil Registry and Vital StatisticsDivision includes 59 regular staff members aswell as 80-100 temporary workers.
Although the Civil Registry is functionallywithin the Population and Housing Branch ofthe National Census and Household Surveys De-partment, it is administratively responsible tothe Executive Dkector of the National Census
62
and Statistical Office in his capacity as CivilRegistrar-General.
Training activities of the National Censusand Statistical Office. —The National Census andStatistical Office has attempted to upgrade regis-tration performance. The recently revised Man-ual on Civil Registration,1 quoted frequently inthis chapter, has been circulated to local civilregistration offices. The regional-provincial-localnetwork of National Census and Statistical Of-fice workers has been used to conduct seminarsand workshops on civil registration. Regional of-ficers are responsible for providing training toprovincial National Census and Statistical Officestaff who, in turn, train local civil registrars.These seminars and workshops are paid for outof city or municipal funds. Rapid turnover ofpersonnel at the local level was cited as a prob-lem hampering the effectiveness of these trainingefforts.
‘Ihe National Census and Statistical Officehas also sponsored or cosponsored national semi-nars on civil registration. A recent seminar washeld in Manila on April 17-18, 1975, and wasapparently conducted as a result of a suggestionmade by the City Health Officers Association (p.183 ). Approximately 100 local civil registrarsparticipated in this seminar. .
Local Level
Although the legal basis for civil registrationisestablished by national law and the productiondf vital statistics requires aggregated data, imple-mentation of civil registration is primarily a localaffair. For this reason, the activities undertakenat the local level will be comprehensively de-picted.
Local civil registrars. –Local civil registrarsrepresent the legal authority of the Governmentin the field of vital registration. They are thetreasurers of the regular municipalities and mu-nicipal districts and in cases of chartered citiesthey are the city health officers or other personsdesignated by the city charter.
In some chartered cities, the position ofdeputy local civil registrar is provided to assistthe local civil registrar. The local civil registrarsof municipalities and municipal districts are per-mitted to designate assistant local civil registrarsfrom among their senior employees or the prin-cipal clerk of their offices. Local civil registrars
and their assistants and deputies serve under thedirection and supervision of the Civil Registrar-General. Altogether there are slightly more than1,500 local civil registrars.
Duties of local civil registrars are specified inSection 12 of the Civil Registry Law (Act No.3753 ) and described as follows in the Adminis-trative Order No. 1/1975 governing the applica-tion and enforcement of the Civil Registry Law::
“Rule 3. Local Civil Registrars shall: (a) ac- “cept all registrable documents includingjudicial decrees affecting the civil status ofpersons; (b) transcribe and enter immediate-ly upon receipt all registrable documents andjudicial decrees affecting the civil status ofpersons in the appropriate civil register; (c)send to the Office of the Civil Registrar-General, within the first ten days of eachmonth, duplicate copies of all documentsregistered during the preceding month; (d)issue certified transcripts or xerox copies ofany certificates or documents registered, up-on payment of the prescribed fees; (e) clas-sify and bind all registry certificates or docu-ments; (f) index the registered certificates ordocuments to facilitate verification of anydocuments; (g) administer oaths free ofcharge for civil registration purpose; and (h)perform such other duties as may be neces-sary in connection with civil registration. ”
Civil Register Books
“Rule 4. Every Local Civil Registrar shallfile, keep and preserve in a secured place inhis office the following” books, in which heshall make the proper entries affecting thecivil status of persons
(a) Register of births;(b) Register of deaths;(c) Register of marriages;(d) Register of annulment of marriages;(e) Register of void marriages;(f) Register of legal separations;(g) Reg!ster of legitimation;(h) Regyster of acknowledgements;(i) Register of adoptions;(j) Register of changes of names;(k) Register of naturalizations;(1) Register of elections of Philippine citi-
zenship;
83
by
64
(m) Register of repatriations;(n) Re@ter of ci~il interdictions;(o) Register of judicial determinations of
filiation;(p) Register of voluntary emancipation of
minors; and other registers which maybe required by law or by the Civil Reg-istrar-General.” (p. 791)
(See also “Local Registers,” this chapter.)Some amplification of these rules is providedthe text of the Manual of Civil Regz”stration:
“The Local Civil Registrar as a representativeof the Civil Registrar-General is responsiblefor the civil registration program in his city/municipality. He shall be knowledgeable ofthe Civil Registry, pertinent Books andTitles of the New Civil Code, Presidential de-cree No. 651, Administrative Order No. 1,Series 1975, and all other pertinent pro-visions of the Law that has direct bearing onthe civil registration matters.
“He shall routinely carry out the duties andresponsibilities listed in the pertinent laws,revised rules and regulations governing theapplication and enforcement of the CivilRegistry Law, Act No. 3753, in the light ofPresidential decree No. 651 as incorporatedin Administrative Order No. 1, Series 1975.
“He shall publicize his office as well as theobligations of the public, in such a way as toobtain complete and prompt registration.
“He must examine the records presented tohim for registration and critically review allcertificates for completeness, legibility andaccuracy.
“Example: Check spelling of names, checkdate, and signatures, etc. He shall sign anddate all certificates when he accepts themfor filing. He shall maintain useable file of allrecords and keep up-to-date the posting en-tries in the corresponding Civil Registrars.
“He shall collaborate with regional/provin-cial/municipal census officers of the NCSO[National Census and Statistics Office]., asthe case may be in conducting educationalcampaign for improving the level of registra-tion to implement fully Presidential decreeNo. 651.” (p. 51)
Under Section 18 of the Civil Registry Law(Act. No. 3753),
“Any local Civil Registrar who fails properlyto perform his duties in accordance with theprovisions of this Act and of the regulationissued hereunder, shall be punished, for thefirst offense, by an administrative fine in asum equal to his salary for not less than fif-teen days nor more than three months, andfor a second or repeated offense, by removalfrom the service. ”
It should perhaps be reemphasized here thatall local civil registrars serve in an ex-officiocapacity and receive no compensation for theirregistration responsibilities. Municipal treasurersare administratively responsible to the Secretaryof Finance and Health, officers to the Secretaryof Health. The requests for sanction have to beaddressed to the appropriate authorities and arepractically never implemented.
REGISTRATION
Forms for Registration and Certification
Forms for certifying and registering births,deaths, fetal deaths, and marriage contracts(municipal Forms No. 102; 103; p. 31, 103-A;and 97) are printed by the Bureau of Printing.The responsibility for acquiring and maintainingthese forms is as follows:
“It is the responsibility of the Local CivilRegistrar to have sufficient supply of printedforms available; namely, Municipal FormNo. 102, Certificate of Livebirth; No. 103,Certificate of Death; No. 103-A, Certificateof Foetal Death; and No. 97, Marriage Con-tract. Public hospitals, since they do notcharge extra cost for providing blank certifi-cates, are to be supplied by the local govern-ment where the hospital is located. Privatehospitals/clinics should provide their ownforms.
“Purchase of these standard forms is thefunction of the provincial treasurer andrequisitions may be coursed through the Of-fice of the Provincial Treasurer. However,direct orders to the Bureau of Printing maybe done provided a money order coveringthe requisition is attached to the Requisition
Issue Voucher (RIV). Funds for such ‘pur-chase are paid by the Local/City Govern-ment conceme”d.
“The purchase of these standard forms’ fromprivate printers is prohibited by law (Circu-lar No. 3, Series 1973, dated February 12,1973*” (p. 431 )
Although local governments are expected topay for these forms from local funds, recentNational Census and Statistical Office policy hasbeen to supply forms (specially marked “Not for%lc”) to localities that are unable to purchasethem. The cost of the standard forms is approxi-mately 10-12 centavos per copy (about$0.13-$0,16); because each ‘certifiable eventmust be reported in triplicate ,e the forms foreach registration cost approximately 35 centavos(about $0.48).
Standard forms for other types of civil regis-trations are not printed centrally. However,model forms for certifying and registeringfoundlings, and registration of repatriations,election of Philippines citizenship, naturaliza-tion, legitimation, adoption, acknowledgmentsof natural children, and changes of names aremovided to serve as exarrmles for forms ~ro-~uced locally. (p. 431) A
.
Informant
As a general rule, every vital event should beregistered in the office of the local civil registrarof the city or municipality where the event oc-curred.
The requirements for informants differ ac-cording to the type of event, place of occurrence,and other contingencies. These may be brieflysummarized as follows:
Bz’rth.-Presidential Decree No. 651 states:
“Babies born after the effectivity of this de-cree must be registered in the office of thelocal civil registrar of the Rlace of birth with-in thirty (30~ davs after b{rth, bv the attend-,. .,ing phy’si~ian, nurse, midwife, hilot,f or hos-
cAlthough the forms are marked “Complete induplicate,” triplicate forms seem to be completed inpractice.Theoriginal copy goes to the parents, survivors,or married couple; one copy is retained for the localregister; the other is forwarded to the office of the CivilRegistrar-General.
fA hilot is the t~adition~ fid~f~.
pit~ or clinic administrator or, in default ofthe same, by either parent or a responsiblemember of the family or any person who hasknowledge of the birth.
“The parents or the responsible member ofthe family and the attendant at birth or thehospital or clinic administrator referred toabove shall be jointly liable in case they failto register the new born child. If there wasno attendant at birth, or if the child was notborn in hospital or maternity clinic, then theparents or the responsible member of thefamily alone shall be primarily liable in caseof failure to register the new born child.”
A slightly different formation of liability isgiven in the Administrative Order No. 2/1975governing the application and enforcement ofPresidential Decree No. 651:
“Rule 8. The physician, nurse, midwife orhilot in attendant at birth, the administratorof the hospital or clinic where the child wasborn, the parents or a responsible member ofthe family are jointly liable for failure toregister the child as required by this decree.In default of any person in attendance, theparents shall be primarily liable for such fail-ure. ”
Thus it appears clear that the responsibilityfor births in hospitals or clinics is jointly sharedby birth attendants, hospital administrators, par-ents, and other family members. In 1974, 23.7percent of reported births occurred in hospitals.The unattended home deliveries must be re-ported by parents or others having knowledge ofthe birth. Approximately 13.3 percent of regis-tered birth certificates indicated that the birthattendant was other than a physician, nurse,midwife, or traditional midwife (hilot) or failedto state an attendant at birth. Some ambiguityoccurs, however, fixing the responsibilityy forbirth registration in the case of attended homedeliveries, which appear to contribute nearlythree-quarters of all deliveries. This ambiguity isfurther compounded by the anomalous status ofhilots. A few Provinces have established Ii-censure procedures for hilots and this wasthought to have beneficial effects on the com-pleteness of registration.
65
Deaths. –Referring to deaths occurring afterits effective date,’ Presidential Decree No. 651states:
““Deaths occurring after the effectivity ofthis decree must be reported by the nearestresponsible relative or apy person who hasknowledge of the death within 48 hoursafter death to the Local Health Officer ofthe place of death; who shall then issue thecorresponding certificate of death and orderits registration in the office of the local civilregistrar within thirty (30) days after death.In case the deceased was attended by aphysician the latter must issue the necessarycertificate of death within 48 hours afterdeath and submit the same to the localhealth officer of the place of death, whoshall order its registration in the office of thelocal civil registrar within the said period ofthirty (30) days after death.”
Perhaps the most important point to benoted regarding death is that certification is theresponsibility of the attending physician or localhealth officer; the local civil registrar is respon-sible for registration, but not certification, ofdeaths. Slightly more than one-third of reporteddeaths in 1974 were either not medically at-tended or attendance was not stated. Both theCivil Registry Act and the implementing rulesand regulations prohibit burial in the absence ofa death certificate.
Fetal and infant deaths.–
Fetus born dead at any stage of gestation–aCertificate of Fetal Death is issued for statis-tical purpose.
Liveborn fetus of less than 7 months’ gesta-tion who dies within 24 hours of birth-aCertificate of I-he Birth and a Certificate ofDeath are issued, each of them bearing themention “for statistical purposes only.”
.The Civil-Registry Law does not provide fora register for fetal deaths.
A4amiages.-L0cal civil registrars ire respon-sible for issuing marriage licenses as well as forregistering marriage contracts. Applications formarriage licenses require that the contractingparties swear that they have the necessary quah-fications for contracting marriage. Additional re-quirements are proof of age through birth or
baptismal certificates or testimony of parents orby affidavit. Males under age 20 and females un-der age 18 must further furnish proof of consentof parents. Males between the ages of 20 and 25and females between the ages of 18 and 23 arerequired to ask parents or guardians for adviceupon the marriage; in the event such advice isnot given or is unfavorable, the marriage must bedelayed for 3 months after the application forlicense. Widowed and divorced persons are re-quired to present death certificates of the de-ceased spouse or divorce decrees. If the birthcertificate cannot be found, an affidavit is ac-cepted. Notice of the application for a marriagelicense must be posted for 10 days before thelicense is issued. Licenses can be issued by thelocal registrar of the municipality where eitherparty resides. Marriage licenses can be waived for“marriages of exceptional character” which aredefined on the basis of distance between thebride’s house and the municipal building or ifone of the contracting parties is on point ofdeath, or in solemnization of common lawunions of 5 or more years’ duration.
The marriage contract requires signature bythe contracting parties, the person solemnizingthe marriage, and two witnesses. The contract iscompleted in triplicate. The person authorizedto solemnize the marriage is required to submittwo copies to the loc~ civil registrar within 15days of the celebration of ordinary marriagesand within 30 days of the solemnization of mar-riages of exceptional character.
Witnesses
For timely registration no additional wit-nesses are required other than those just de-scribed in connection with the Marriage Con-tract. However, collaborative testimony is re-quired in delayed registrations as will bedescribed.
Delayed Registration
Chapter VII of the Manual of Civil Regirtm-tion is directed to issues concerning delayedregistration. 1
If an event is registered late it is entered inthe civil register in red ink and whenever a certi-fied copy or transcript is issued, the words “lateregistration” are written or typed in the upperright hand comer of the certificate.
ae
Registration of birth, death, or marriage, of6 months’ delay, becomes a case for investiga-tion and possible penalty.
Should a birth be registered more than 30days after it occurs, other requirements must bemet, depending on the length of the delay.Should the delay extend to 18 years or more, apolice investigation may be authorized and theapproval of the Civil Registrar-General is re-quired to register the birth.
Delayed registration of deaths requires thatthe local civil registrar be convinced (after pres-entation of an affidavit reporting place, date,and cause of death, and an’investigation into thedeath) of the truth of the facts of death.
Delayed registration of marriages requires a‘statement of the reasons for delay, and, in caseof doubt, an investigation into the marriage con-tract. If the local civil registrar is convinced ofthe truth of the facts, he may register the mar-riage.
If a report of delayed registration is deniedby the local civil registrar, it may be appealed tothe Office of the Civil Registrar-General to bereconsidered,
Feesfor Registration of Events
Presidential Decree No. 651 requires thatbirths and deaths that occurred from January 1,1974 up to March 15, 1975 be registered in theoffice of the local civil registrar c~ncerned up toMay 18, 1975 without fine or fee of any kind.Presidential Decree No. 766 is an amendment toPresidential Decree No. 651 extending theperiod of registration up to December 31, 1975without fine or fee of any kind; it was againfurther extended by Administrative Order No. 1,Series of 1975 up to December 31, 1977.
Fees for the registration of other vital eventsare stipulated in the local tax code as follows:
Us.Peso dollars
Marriage fees:Application fee ....... ~10.00 $1.35License fee ............. 2.00 0.27Solemnization fee... 3.00 0.41
Burial permit fee .......... 1.00 0.14Fee for exhumation ...... 1.00 0.14Fee for removal of
cadaver .,, .................... 3.00 0.41
Registration fees on the civil status of per-sons—for the registration of documents and forcertified copies of documents on file in the of-fice of the local civil registrar:
Us:Peso dollars
Per registration oflegitimation ....................... F5.00 $0.68
Fer registration of anadoption ............................. 5.00 0.68
Per registration for an snnul-ment of marriage ................ 15.00 2.03
Per registration of divorce ..... 15.00 2.03Per registration of a
naturalization .................... 30.00 4.06For certified copies of any
document in the registrar,for each 100 words ............ 1.00 0.14
(p. 441)
Cettified Copies
Request for certified copies of civil registryrecords may be made from the office of thelocal civil registrar or Civil Registrar-Generalupon payment of the required fee. Anyone canmake such a request except for birth recordswhich is subject to the limitation imposed byArticle 7 of Presidential Decree 603 whichprovides:
“(1)
“(2)
“(3)
“(4)
the person himself, or any personauthorized by him;
his spouse, his parent. or parents, hisdirect descendants, or the guardian orinstitution legally in charge of him ifhe is a minor;
the court or proper public officialwhenever absolutely necessary in ad-ministrative, judicial or other officialproceedings to determine the identityof the child’s parents or other circum-stances surrounding his birth; and
in case of the person’s death, thenearest of kin. ”
Fees.–Fees for issuance of copies of recordsand documents are set forth as follows:
Us.Peso dollars
For every 100 words orfraction thereof, type-written (not including the
67
certificates and anynotation) ............................... P1.oo $0.14 ‘
Where the copy to be fur-nished in a printed form,in whole or in part, foreach page (double this feeif there are two pages ina sheet) .................................. 2.00 .0.27
For each certificate ofcorrectness (with seal ofoffice) written on the copyor attached thereto ................ 2.00 0.27
For copies furnished otherbureaus, offices andbranches of the governmentfor official business (ex-cept those copies requiredby the court at the requestof litigants, in which casecharges should be made inaccordance with the aboveschedule ) ................................ Free
For certifying the officialact of a municipal judge orother certificate (judicial),with seal................................ 2.00 0.27
For certified copies of anypaper, record decree, judgmentor entry of which any personis entitled to demand andreceive a copy (in connectionwith judicial proceedings,for each 100 words) .............. 1.00 0.14
Xerox or any other copyproduced by copying machine,per page................................. 2.00 0.27
Photocopy, per page.............. 5.OO 0.68
However,
“The Civil Registrar may issue certifiedcopies of a competent court or other govern-ment agency. The issuance of certifiedcopies of birth certificates of children reach-ing school age when such certificates are re-quired for admission to the primary grades ~of the public schools shall be considered of-ficial and given free of charge.” (p. 441)
It appears that local practice regardingcharges for copies of certificates varies consider-ably.
Burial PermitsRule 19 of Administrative Order No. 1,
Series of 1975 governing the application and en-forcement of the Civil Registry Laws stipulatesthat “No human body shall be buried without acertificate of death issued either by the localhealth officer or attending physician within 48hours after death.” A copy of the Certificate ofDeath shall be attached to the transfer permitissued for burial to another place other than theplace of death. LocaI civil registrars have nojurisdiction over matters relative to the issuanceof burial, transfer, and conveyance permits, Thepermits for burial, transfer, or conveyance areissued only by the city or municipal secretary,upon presentation of a proper Certificate ofDeath. The city or municipal secretary does notissue a ‘permit without a proper Certificate ofDeath. However, the registration of the Certifi-cate of Death shall be made in the place of deathand not at the place of the burial (except if theexact place of death cannot be determined).
Special ProblemsThe special cases probably have only a mini-
mal impact on the effectiveness of the registra-tion system.
llle~”timate child-h the case of an illegiti-mate child, the birth certificate is signed andsworn to jointly by both parents, or the motheralone, if the father refuses. In the latter case thecertificate must not contain any information bywhich the father could be identified.
FozmcZling.-The person who finds a child isresponsible for reporting that fact to the localcivil registrar. The finder has to execute an affi-davit giving the place, date, and hour of findingand other attendant circumstances.
A Certificate of a Foundling (Civil Regis-trar-General Form No. 101) is registered in theoffice of the local civil registrar of the placewhere the infant or child was found, if the placeof birth is not known.
A child who is taken from a charitable institu-tion or orphanage for registration is considereda foundling if the parents and the facts andcircumstances of birth are unknown. In thiscase, the Certificate of a Foundling is registered
in the office of the local civil registrar of theplace where the charitable institution or orphan-age is located.
Other cases.-Administrative Order No. 1,Series of 1975 states the procedures to be fol-lowed for:
Birth of a child in a vehicle, vessel, or air-plane in transit within Philippine territory(Rule 9).
Death of a person in a vehicle, vessel, or air-plane in transit within Philippine territory(Rules 22 and 23).
Death of a Filipino in a vessel in the highseas (Rule 24).
Local Registers
The New Civil Code of the Philippines pre-scribes (Article 407, Book I, Title XVI) that“Acts, events and judicial decrees concerning thecivil status of persons shall be recorded in thecivil register.” (See also “Local Civil Registrars,”this chapter.)
All register books of births and deaths; in-cluding all supporting Municipal Forms Nos.102, 103, and 103-A should be in the custody ofthe local civil registrar.
Procedures for maintaining local registers aredescribed in the Manual of Civil Registration as
“ follows:“The receipt, entry in the civil register, bind-ing and filing of the various types of civilregistry records, like the certificates of birthsand deaths, marriage contracts, marriage li-censes and other refistrable documents shall
I be done separately ~or each document and in.accordance with the following instructions:
“Before receiving any document for registra-tion, examine the document and see whetherall the items thereof are completely filledand signed by the informant. Documentswith items not sufficiently filled out or withany error have to be returned to the appli-cant who has to fill a new certificate.“If you are satisfied that the requirementshave been fully complied with, accept thedocument for registration. Stamp the date ofreceipt or write it on the upper right handcorner of the document. This is to be ini-tialed by the Local Civil Registrar or hisauthorized clerk.
“Record the date of receipt in a logbook orrecord book. This is especially importantwhen the office of the Local Civil Registrarreceives large numbers of documents every-day. This will enable tracing misplaced orlost documents during the posting of the en-tries in the civil registers. Responsibility forsuch losses can easily be pinpointed.
“File documents as they are received, faceup, the latest report on top, for facility indetermining the next number to be assignedto the incoming document.
“Enter the registry number of the documentin the space provided in the certificate.Numbering of the civil registry, documentsbegin with “1” at the start of the year. Thus,the first birth document received shall benumbered: 1 (a-75). This means the certifi-cate is the first registered for the month ofJanuary (a) and the year 1975 (75). Numberthe documents consecutively, whether thereport is a regular or a delayed report ofbirth, death or marriage.
“When the report for each event exceeds1000 certificates a month, the numberingcan start with “1” for each month.
“The pertinent registration procedures arediscussed fully in succeeding chapters VI andVII. It must be stressed here that the LocalCivil Registrar shall see to it that the postingof information from the certificates of vitalevents is to be done in an up-to-date manner.
“After a document has been given a registrynumber, enter immediately the informationrequired in the civil register following thesequence of the registry number. Do notskip or repeat any number. The delayed re-ports should be entered- in ‘red ink. Anynecessary remarks should be written in the“remark” column. Each item to be enteredin the register should be copied exactly andas accurately as possible to avoid any mis-takes which might inconve-tience the party ata future date.
“List the death documents received daily.This must be prepared in duplicate; onecopy shall accompany the death documentsforwarded to the Local Health Officer and
m
the other copy shall be retained in the Officeof the Local Civil Registrar.
“Death certificates shall be given a registrynumber after they are returned from theoffice of the Local Health Officer (LHO).Always check the certificates ~qtuming fromthe Local Health Officer against the trans-mittal list that went with the documents.See to it that all the documents forwardedare accounted for.
“Where there is a large number of docu-ments received for registration, the” docu-ments may be accumulated and entries inthe appropriate civil register may be madebefore the close of office hours everyday. Itis also advisable to assign a specific personthe task of posting the entries in the registersas soon as they are received.
“Sorting is the physical arrangement of filematerials with the aid of some device tofacilitate and systematize arrangement. Inthe local level, civil registry documents aresorted by subject, that is, either birth, deathor marriage, then by the month and year. Atthe national level, it is sorted by subject,province, municipality, month and year.
“At the end of each month, detach the dup-licate from the original copies of each type ,of certificates received and registered duringthe month. Sort both sets, originals and dup-licates, by registry number.
“Bundle each set of original and duplicatecopies separately by type of document.Label each set properly by month and ye&,with the beginning and ending register num-bers indicated.
“Example: Births, January 1974 Reg. Nos.1-109.
“The set containing the duplicate copies ofthe certificates registered during the subjectmonth shall be forwarded with the properletter of transmittal to the Office of the CivilRegistrar-General. Record during the firstten (10) days of each month, pursuant toSec. 12 of the Civil Registry Law.
“The set of original copies which are thesupporting documents of the entries in theregister, shall be retained in the Office of the
Local Civil Registrar for binding and filingand for the preparation of indexes to facili-tate reference.
“The documents which had been sorted bymonth and year shall be fastened or heldtogether in folder or book form, one folderto contain about 500 documents. Numberthe folder consecutively starting with “1”for the first folder in January, etc., up to theend of the year. One folder may contain thedocuments for more than one month, de-pending on the number of vital events regis-tered.
“Label each folder or book form designatingits contents. Lettering shall be in uniformstyle, using India or any black unfading ink.“Example:
1974January to MarchReg. Nos. 1-500Pages 1-500
“The documents shall be
1974April to JuneReg. Nos. 501-800Pages 1-300
indexed to facili-tate search and verification. Subjected to toomuch handling, the records on file may be-come tom and defaced and indexing mini-mizes such handling and keeps the records ingood order. Indexing may be done manuallyon index cards, listing and arranging inalphabetical order names of the parties inorder to facilitate reference. For voluminousrecords, IBM indexed print outs are prefer-able.
“Arrange folders in consecutive order fromJanuary to December in filing shelves, filingracks, or cabinets, by year and by registrynumber. The test in the efficiency of a filingsystem is the ease by which any desiredrecord can be located.
“The Marriage Registers, Birth Registers,Death Registers and Register for Applica-tions of Marriage License and supportingdocuments shall be open to the publicduring office hours. Precaution and closesupervision should be exercised to avoidtampering, loss or destruction of these rec-ords. These records shall not be removedfrom office, except by order of a court, inwhich case proper receipt shall be taken anda certified copy retained in the office files.
70
“h-r locating the certificates of vital eventsbeing requested for, see that a duly desig-nated person shall attend to the verification.No verification is to be made withoutauthority from the Local Civil Registrar whois in-charge of all records and who has closesupervision in this regard. The Local CivilRegister must be informed of results of anyverification work done and such releases ofinformation must be recorded in a properlogbook for future references.
“All vital documents are for public informa-tion which may be released only uponproper request on an individual basis. Be-yond this, all records are confidential andinformation may be released only to thosewith a direct and tangible interest in a recordand this generally include next of kln andlegal representatives, such as attorneys, in-surance companies and banks. Informationor certified copies should not be released toother persons unless they can show theirneed for the information.
“MI births, deaths, foetal deaths and mar-riage certificates and all registrable docu-ments should be filed in the Local CivilRegistrar Office. It is his duty to keep allthese documents safely and maintain themorderly at all times, being responsible fortheir safekeeping and preservation and liablefor negligence, tampering, loss or damage ofany of those documents. He may be chargedwith infidelity in the custody of publicdocuments, if any record is lost or destroyedthrough his own fault or negligence.” (pp.9-111 )
It must be underlined that “The booksmaking up the Civil Register and all documentsrelating thereto shall be considered public docu-ments and shall be prima facie evidence of thetruth of the facts therein contained” (Section13, Act No. 3753 and Act No. 410, Book I,Title XVI, New Civil Code of the Philippines) (p.591 ).
Local Civil Registrar
One of the main duties of the local civilregistrar is to disseminate information on civil
registration and to keep the public well in-formed on revision, amendments, and innova-tions on the registration procedures. To fulfillthis mission, the local civil registrar is advised tomaintain close contacts with all collaboratingagencies and local authorities present in hiscity/municipality who can help him:
The religious leaders who must be enjoinedto inquire whether the birth or death hadbeen registered before baptism or perform-ance of religious death rites.
The school teachers who have to request abirth certificate when a child first entersschool.
The local revenue officer, as the birth certifi-cate is a legal prerequisite for allowance oftax exemption for additional dependents.
The rural health units and the health centerswhich are aware of events occurring in thecommunity.
The hospital administrator who is the keyperson for the local civil registrar to contact.
The local census officer when an educationalcampaign for improving the level of registra-tion is conducted.
In addition, the assistance of all barrio cap-tains and barangay chairmen is explicitly en-listed in the registration of birth and deathwithin their respective areas of responsibility.
Presidential Decree No. 651 stipulates that“all barrio captain and barangay chairmen shallhave responsibility for disseminating the decreeamong their constituents and for assisting in theregistration of births and deaths occurring with-in their respective jurisdictions to insure com-plete coverage of these events.”
Administrative Order No. 2, Series of 1975,,instructs all barrio captains and barangay chair-men “to determine whether all births and deathsoccurring within their respective jurisdictions,from January 1, 1974 onwards have been regis-tered and, if not, to take appropriate steps tocause registration. . . .” It is underscored that“on the performance of their duties and respon-sibilities relative to Civil Registration they shallbe under the direction and supervision of the
71
Civil Registrar-General or his authorized repre-tentative. ”
To implement these regulations, the Manualof Civil Registration delineates the role of theseelected but uncompensated officials as follows:
“The barrio captain or barangay chairmanshall visit periodically every household with-in the barrio or barangay or as often as pos-sible for the purpose of checking whether” abirth or death occurred.
“Should there be a new baby born, he shallinquire whether or not the birth has beenregistered. He shall cause a Certificate ofLive Birth (Mun. Form 102) to be accom-plished and registered in the Office of theLocal Civil Registrar within 30 days afterbirth. In filling up the certificate, the motheror any other informant should be asked tosupply the correct answer or information inthe personal items of the certificate and signin Item 17.
“Should there be a death and where nodeath certificate had been prepared, he shallcause the reporting of the death to the LocalHealth Officer for the issuance of a deathcertificate within 48 hours after death, al-though such accomplished certificate ofdeath shall be registered in the office ofLocal Civil Registrar of the city/municipalitywithin 30 days after death.
“He shall request for his supply of certifi-cates of birth and certificate of death forms(Mun. Form Nos. 102 and 103) from theOffice of the Local Civil Registrar.”
Discussion with civil registration officialsseemed to indicate that barrio captains andbarangay chairmen varied considerably in theirfulfillment of these responsibilities.
An important recent development likely tohave a bearing on registration completeness isthe establishment of an extensive network offield employees of the National Census and Sta-tistics Office. In particular, current efforts arebeing expended to provide a municipal censusofficer or a municipal census assistant for eachmunicipality. These persons are expected toassume a number of registration responsibilities,
including corroboration of total number ofevents registered and for coding certificates priorto forwarding them to the Manila office of theNational Census and Statistics Office.
As previously noted, the local health officer‘hnd the local civil registrar collaborate on deathcertifications and registrations. Until 1974, theDepartment of Health collected vital statistics in-formation directly through the monthly reportsof the local health officers. These officials inturn secured their information on births fromthe local registers. Although the data providedthrough this system are no longer being ana-lyzed, the data are apparently still being col-lected.
Vital Records
Routing. –Under Section 12(e), Civil Reg-istry Law (Act No. 3753), it is the duty of thelocal civil registrar to send the Office of the CivilRegistrar-General, within the first 10 days of themonth, duplicate copies of the entries madeduring the previous month, with the proper reg-istry numbers.
The local civil registrars are instructed tosend these monthly reports to reach the Officeof the Civil Registrar-General before the end ofthe month or (for far-away municipalities andcities) during the first week of the followingmonth.
The set containing the duplicate copies ismailed, exempted from the payment of ordinarypostage.
A letter of transmittal showing the numberof records in each category is also forwarded.
As they are received, records are sorted bymunicipality and province. The number ofrecords in each registration category is checkedagainst the number indicated in the transmittalletter and inquiries are initiated in case of dis-crepancies. As noted earlier, an additional checkmay soon be available from the reports of themunicipal census officers/census assistants.
The requirement to submit registrationdocuments promptly is not always met. In part,this is apparently due to difficulties in transpor-tation and communication; but in part, delaysappear to be caused by the need to compile sta-tistics locally. Thus, for example, the City ofManila is substantially in arrears because the
72
copy submitted to the National Census and Sta-tistics Office is keypunched locally before sub-mission.
Editing and coding. –Editing and coding iscarried out by the editing and coding staff.Codes are supplied for 17 items on the birth certif-icate, 13 items on the death certificate, 16 itemson the fetal death certificate, and 12 items on memarriage certificate. New coders’ work is veri-fied; the error rate is said to be small. Codes areentered along the right margin of each certifi-cate. The coding of information in box 16 of thebirth certificate calling for information on pre-vious deliveries, total live births, and total chil-dren currently alive was mentioned as a specialproblem owing to discrepancies and/or omis-sions. An explicit set of rules dealing with theseproblems has been developed, but these rules arenot felt to be entirely satisfactory. Some prob-lems with the cause-of-death codes were alsomentioned, but appear to arise from erroneousinformation on the death certificate rather thanfrom errors in coding as such.
As previously noted, field editing and codingby the municipal census officers/census assist-ants in the field is contemplated and is expectedto take effect by the end of calendar year 1977.As this plan becomes operational, a 100 percentcoding verification in the central office will beinitiated. Although it would appear that fieldediting and coding might offer some advantagesin terms of detection and correction of errors,this potential advantage is offset by the fact thatinformation on the certificates cannot bechanged except under court order.
When coding is completed, registration cer-tificates are bound into folders each containing400 records. The records are assigned consecu-tive page numbers. The book number of thebound volume and the page number are subse-quently keypunched as part of the encodedrecord. The book and page references are subse-quently used in record searches.
Keypunching and processing. –Books of en-coded records are routed to the National Censusand Statistical Office data processing units,where key to tape machines are used to recordthe data. The bound volumes are then returnedto the Civil Registry for permanent storage.
Problems with processing of vital recordsappear to be mainly in the areas of breakdowns
of machinery and competition with other proj-ects for machine time. With respect to theformer, it appears that intensive use is made Gfthe available equipment. Keypunchers work 24hours a day, 6 days a week in 3 shifts; the com-puter operates on a 3-shift, 7-day schedule.However, overheating problems are frequent andup to 6 hours a day are spent in allowing ma-chines to cool down.. The present air-condition-ing arrangements are reported to be inadequate.
Competition with other responsibilities iscurrently reflected in the priority given to com-pletion of tabulation from the 1975 census,which is somewhat behind schedule. The mostrecent published report on vital statistics is forthe year 1974. Results for 1972 were publishedin 1974 and results for 1973 were published in1975. This publication must be viewed as rathertimely, since the official date for “closing thebooks” on a calendar year of registration reportsis presently July of the following year. Pres-ently, consideration is being given to establish anearlier closure dates. Such a practice wouldprobably speed up production, but might de-crease coverage due to exclusion of registrationsreceived late. At present, delayed registrations ofvital events (those received after the statutoryperiod for registration has ended) are not key-punched and no attempt to update tabulationson the basis of delayed registrations has beenmade.
Storage.–The National Census and StatisticsOffice maintains files of all vital records re-ceived. Recently, experimental trials of micro-filming equipment have been conducted. Resultsindicate that one unit could about keep pacewith the volume of records currently received atapproximately F200,000 per year (about$27,082). If an additional machine were ac-quired, it would take about 9 years to microfilmthe backlog of records on file. The main ad-vantage of microfilm is space saving. This isbeing weighed against the additional costs of in-stal~ng a microfilm system.
The Civil Registry records presen~y filed mthe Archives of the National Census and Statis-tics Office are all records of births, deaths, andmarriages all over the Philippines covering thelate part of 1945 to date. These include courtdecrees and legal instruments. All Civil Registryrecords filed in the Bureau of the Census and
73
Statistics prior to the late part of 1945 weretotally destroyed during the Second World War.
UTILIZATION OF STATISTICSDERIVED FROM THE CIVIL
REGISTRATION SYSTEM
Civil registry records have a wide variety oflegal, protective, administrative, and statisticaluses. The legal and protective functions of civilrecords derive mainly from use of the individualrecords; administrative and statistical uses, forthe most part, require that the records be aggre-gated and analyzed. In the present section, someof the administrative and statistical uses of civilregistration data will be considered. In the nextsection, uses of individual records will be dis-cussed.
Department of Health
Perhaps the most extensive traditional usemade of vital statistics’ is in identification ofhealth problems and the planning and deliveryof health care systems. As previously indicated,the local health officer plays an important rolein the certification of deaths and links directlyto the local civil registrar. At the national level,the Health Department was, until 1974, engagedin the compilation of vital records. Although, atpresent, the Department of Health receives itsinformation on the numbers of vital events intabulated form from the National Census andStatistics Office, it continues to be a major userof these data through its analysis of vital andhealth statistics from the civil registrationrecords and through its dissemination of infor-mation to the various divisions of the Depart-ment of Health, including the regional, pro-vincial, and local health offices.
It should be noted that the Department ofHealth, like any organization, undergoes con-siderable change over time. At the time of thiswriting, several developments which are likely tolead to reorganization of certain Health Depart-ment functions could be identified. ‘These in-clude current plans to eventually extend Medi-care coverage to all citizens (presently, only gov-ernment workers and employees covered by thesocial security system are covered under Medi-
care ), and the projected development of aHealih Management Information System whichwould embody data on vital and health statis-tics, health service statistics, health manpower,and other information needed for administrativepurposes. The implications of these develop-ments for the organization of the Department ofHealth have not yet been fully worked out.Hence the present discussion refers to the cur-rent organization of the Health Department andcurrent utilization of vital statistics.
The Disease Intelligence Center is the mainsource and depository of data and informationin the Department of Health on disease occur-rence and distribution in the Philippines. It is,therefore, the health statistical office at the na-tional level. The Disease Intelligence Center isorganizationally set up to consist of two di-visions, namely, the Division of Epidemiologyand the Division of Health Statistics, which iscomprised by the vital and morbidity statisticssection and the research and service statisticssection.
Both divisions utilize the regional, provin-cial, and local network of health officers in col-lecting data on morbidity and infectiousdiseases. Three more or less district reportingsystems are in current use: the index area sys-tem, the weekly notification of communicablediseases, and the monthly reports of natality,mortality, and morbidity.
The index area system at one time coveredapproximately 200 areas. Criteria for inclusionin the index area system included a populationof 50,000 or over, presence of a health officerwith formal public health training, and telegraphfacilities. The latter was a necessary requirementbecause the system depends on telegraphed re-ports of total deaths, infant deaths, and unusualdeaths. Apparently, the system has fallen intodisuse, since only about 10 percent of the unitsoriginally included in the system continue tosubmit reports. However, there are apparentlysome plans to revive the system.
The communicable disease reporting systemconsists of weekly reports submitted by city andmunicipal health officers simultaneously to theprovincial health departments and to the DiseaseIntelligence Center. This system covers, intheory, 28 communicable diseases, including 4quarantinable diseases. However, since only one
74
of the quarantinable diseases, cholera, is ac-tually endemic in the Philippines, the system, inpractice, reduces to 25 diseases.
The monthly reporting system covers births,deaths, infant deaths, and morbidity as reportedby local health officers. Prior to 1973, theHealth Department operated its own systems forprocessing birth and death data and compiledvital statistics based on its own tabulations. Al-though, in theory, counts of births and deaths inthe Disease Intelligence Center should have beenidentical to those reported by the National Cen-sus and Statistics Office (since both derive frombirth and death certificates), in practice totalsdiffered somewhat; with the Health Depart-ment’s figures usually being somewhat higher.There are at least two possible explanations forthe dkcrepancies. First, some events certified bylocal health officials may not actually have beenregistered by the local civil registrar, or if regis-tered, may not have been forwarded to the Na-tional Census and Statistics Office. Second, aspreviously noted, the National Census and Sta-tistics Office excludes delayed registrations fromits tabulation system; it appears likely that de-layed registrations were, at least, to a certainextent, included in the Disease Intelligence Cen-ter system.
Starting March 1, 1973, the Disease Intelli-gence Center stopped renting IBM key punchand tabulating equipment and made arrange-ments with the National Census and StatisticsOffice for the mechanical processing of data onbirth and deaths. However, it does continue,under the same agreement with the NationalCensus and Statistics Office, to produce analysesof vital and health statistics. -
Since it is recognized that both birth anddeath registration are incomplete, little emphasisis given to the absolute level of vital rates. Re-ports published by the Disease Intelligence Cen-ter do discuss trends in vital statistics, specifi-cally in crude death rates, infant mortality rates,and maternal mortality rates. More attention isgiven to such basic indicators of health andhealth system operation as cause-of-death statis-tics, proportions of births and deaths medicallyattended, proportions of births and deaths oc-curring in hospitals, and similar indicators.
Mortality statistics are also used by theDisease Intelligence Center as a means of cor-
recting morbidity statistics. Thus if the numberof reported deaths resulting from a particulardisease category exceeds the incidence of the re-ported cases in the same category, the morbidityfigures are adjusted upward.
Population Projections
A fundamental use of vital statistics,whether calculated from registration data or esti-mated from other sources, is in the preparationof population projections. Such projects areoften used as the framework for social and eco-nomic planning and, therefore, have wide ramif-ications for development.
Two different sets of population projectionhave been prepared in the Philippines. The first wascarried out by the National Census and StatisticsOffice with funding assistance from the UnitedNations Fund for Population Activities. Themethodology employed was the component pro-jection method which uses sets of age-specificfertility, mortality, and migration rates to carryeach age-sex group population forward in time.The initial population was based on the adjusted1970 census age distribution. The age distribu-tions of successive censuses and the “South”family of regional model life tables were used toderive age-specific mortality rates rather thanthe incomplete data from the vital registrationsystem. The level of fertility was estimated fromapplication of reverse survival ratios to the 1970age distribution; the age pattern of fertility fromvital registration data was accepted, however, forthe national projections.
In these projections, expectation of life atbirth was assumed to increase from a level of53.5 years for males and 56.8 for females in theperiod 1995-2000. Three assumptions regardingfertility were introduced: the high assumptionwas based on an unchanging tot~l fertilit~ rateof 5.8 children per woman, the low assumptionimplied a decline in total fertility rate to 2.6 for1995-2000 period, and the medium assumptionassumed a decline to 4.2.
Provincial projections were also carried outusing for lack of better information, the samemortality assumptions as were used in the na-tional projections, but varying initial levels offertility in accordance with results from the1973 National Demographic Survey.
75
A more ambitious population projectionproject is currently under way at the Universityof the Philippines Population Institute. Thisundertaking is part of the collaborative projecton population, resources, environment, and thePhilippine future by the University of thePhilippines.
UTILIZATION OF CIVILREGISTRY RECORDS
Certificate of Live Birth
A Certificate of Live Birth is needed toprove the fact, of birth:
For establishing identity.
For proving parentage.
For tracing ancestry.
For determining legal dependency.
For application for marriage and examina-tion.
For proving inheritance of property.
For settlement of insurance.
As a basis for public health programs.
The birth certificate is also needed to provethe date of birth:
For enrollment in school and educational-benefits.
For right to vote.
For right to enter civil service.
For proof of legal age for marriage.
For automobile license.
For issuance of professional license.
For settlement of pensions.
For enlistment in the Armed Forces.
For social security benefits.
For request of additional tax exemption.
In addition it is needed to prove the place ofbirth:
For establishing citizenship.
For obtaining passports.
For determining basis for immigration andnaturalization.
Certificate of Death
A Certificate of Death is needed to prove thefact of death:
For life of insurance claims.
For settlement of estates.
The death certificate also is used to provefacts about the deceased:
For circumstances of death.
For time and date of death.
For nativity.
For establishing inheritance rights.
For application for second or another mar-riage.
Certificate of Fetal Death or Stillbirth
A Certificate of Fetal Death or Stillbirth isneeded:
To establish certain questions contingentupon family composition and birth order,questions which may deal with rights of in-heritance.
To prove the fact, the date, and the place ofoccurrence for statistical purposes.
Marriage Contract
A Marriage Contract is needed to prove thefact of occurrence of a marriage:
To establish civil status.
To ensure legal responsibilities for familysupport.
To establish next of kin and rights to in-heritance and other legal claims.
76
To confer legitimacy.
To establish emancipation of a minor.
It is ako needed to prove date of marriage inorder to:
Prove date of birth of offspring.
Prove legitimacy of the children to qualifyfor pension, social security privileges, andlegal rights.
The marriage contract is also important toprove place of marriage.
EVALUATION
Registration Completeness
Some demographers had estimated the levelof registration of vital events to be as low as 60percent of actual occurrences. This was also thefinding in a study made by the National Censusand Statistics Office in 1965 which showed thelCVC1of registration of vital events at 60.3 per-cent for birth and 70.0 percent for death. Thisstudy demonstrated that birth registration ismore deficient than death registration.
During the last decade, registration of birthson the nationaI ievel rose from 60 to 79 percent,while that of deaths rose from 70 to 77 percent.Greater increases have even been noted in someregions. Increases from 61 to 97 percent forbirths and from 60 to 92 percent for deaths havebeen attained, but the aim oflattaining at least a90 percent leveI for the country may stilI be inthe future.
For the year 1973, a total number of1,049,290 birth certificates and 283,475 deathcertificates have been received. For the year1974 the numbers were 1,081,073 and 283,975,respectively. When one takes into considerationthe annual population growth, one can evaluatethe extent of the present coverage of civil regis-tration in the Philippines.
Assessment of Vital Rates
The direct measurement of vital rates fromthe civil registry records is not feasible due to
the incompleteness of registration, and the al-ready serious problem is aggravated because theextent of underregistration cannot be readilyascertained. In any case, the vital rates derivedfrom the legal registration system are consideredvery low compared with the estimated ratesfrom different independent investigations.
As derived from the legal registration sys-tem, the historical trend of vital rates in thePhilippines after the Second World War declined.The average birth rate during the period from1948 to 1973 was 28.8 births per thousandpopulation; the average death rate was 8.9deaths per thousand population. These rates arelow when compared with those that could beanticipated given the age distribution of thepopulation.
The national estimates from various studiesshow that the crude birth rate is approximatelybetween 41 and 50 per thousand population forthe period between 1950 and 1970 and thecrude death rate between 11 and 18 per thou-sand population during the same period.4
The POPCOM/NCSO Project
Realizing the need for reliable, if not ac-curate, vital crude rates, the Bureau of Census,now known as the National Census and StatisticsOffice, undertook a nationwide project underPopulation Commission/National Economic andDevelopment Authority/U.S. Agency for Inter-national Development/National Census and Sta-tistics Office subagreement (POPCOM/NCSOproject) to develop a sample registration systemfrom which estimates of vital crude rates, bothat the national level and regional levels, may bereliably obtained.
Considering further that vital registrationfigures for the country, but particularly forlesser developed regions of the country, cannotbe correct, and that the regional differences inrates reflect more variations in underregistrationthan in fertility and mortality, the POPCOM/NCSO sample vital registration project wasstarted also to improve the level of registrationand to estimate the level of national and regionalunderregistration.
The relevant documents describe both tech-nical and administrative difficulties experiencedand present the conclusions which can be drawnfrom the results achieved by the project.
77
There is no doubt that, in the sample areas,the project has made the people atvare that vitalregistration is an important event. Data collectedbetween 1971 and 1974 show that registrationin vital registration improved which confirmsthat people are now more acquainted with theduty to register vital events than they were be-fore. However, the amount of effort that needsto be exerted to overcome the difficulties under-scores the magnitude of the problems to besolved before a fully satisfactory civil registra-tion system can be implemented throughout thePhilippines.
Cause-of-Death Statistics
Diagnoses of causes of death present a num-ber of problems. First, as previously indicated, asubstantial fraction of deaths are not medicallyattended. Hence diagnosis must be made afterdeath on the basis of symptoms reported byfamily members. Second, even in the case ofmedically attended deaths, diagnosis is oftenmade clinically on the basis of presentingsymptoms, rather than on the basis of resultsfrom laboratory tests. Ambiguity of diagnosisplus difficulties in obtaining followup informa-tion has led the Disease Intelligence Center toedit the reported diagnosis.
The statistics related to the causes of fetaldeath are still to be improved as the informationon the disease or condition causing fetal death isfrequently lacking. The Certificate of FetalDeath was introduced more than 20 years ago inreplacement of the stillbirth certificate wherethe cause dld not appear. Shce that time, it ispointed out that the cause of fetal death mustbe properly assigned by using the classificationof causes of stillbirth as a guide. However, it wasnoted during the field visit that “stillbirth” with-out any indication of cause sometimes appearsas one of the 10 leading causes of mortality. Asstillbirth is not mentioned in the tables pub-lished by the Disease Intelligence Center, onecan wonder how it is dealt with.
Factorsof Underre&tration
The causes of underregistration have beenmade evident by those who are responsible forthe system and they are indicated in several
documents signed by Dr. Tito Mijares, CivilRegistrar-General; Mr. Eugenio Venal, Civil Reg-istry Coordinator of the Civil Registry and VitalStatistics Division, National Census and Statis-tics Office; and Francisco Nazaret, SupervisingCensus Statistical Coordinator, Population andResearch Branch, National Census and StatisticsOffice.
These causes may be split into four cate-gories according to the factors liable for the de-ficiencies.
The administration. –Deficiencies mainlyoriginate because financial resources are toosmall. Even if the Civil Registry Law (Act No.3753) provides that “all expenses in connectionwith the establishment of local registers shall bepaid out of municipal funds,” most often thecity or municipal council does not provide thenecessary logistics. The consequences are:
Lack of personnel: The local civil registrarscomplain about the lack of necessary person-nel to handle civil registry work resulting inthe backlog of posting entries on the perti-nent registries.
Lack of office equipment and supplies: Thismakes preservation and safekeeping of civilregistry documents unsatisfactory.
Inadequate supply of registration forms: Theusual reason given is that no fees are beingcollected for the registration of births,deaths, and marriages and that the city/municipality cannot afford to give municipalforms free of charge to the public. To haveavailable funds, some cities/municipalitiesimpose fees for the registration of theseevents, contrary to the rules in the Civil Registry Law.
As noted previously, the National Censusand_ Statistics_ Office supplies forms (speciallymarked “not for sale’~ to localities that are un-able to purchase them.
More generally, the lack of funds keeps theGovernment from improving the level of civilregistration on a nationwide scale.
Local oficiak.-Some local officials do theirjobs poorly; they are negligent and deficient intheir duties. Municipal forms are improperly
78
filled out; documents are submitted late to theOffice of the Civil Registrar-General. Because ofthe ex-officio nature of the civil registry work, itis very difficult to prosecute these local officialsor to punish them for their poor performance.
The population. –Many Filipinos are un-aware of the importance of civil registration andof their responsibilities as set forth in the civilregistration laws. Some, believing that baptismequals birth registration, do not fulfill theparental obligation to register the birth. Death isaccompanied by similar negligence. Attendantsat births and deaths are no better informed oftheir obligations.
External constraints.–Often the place of reg-istration is a great distance to travel, made moredifficult by lack of roads and poor transporta-tion facilities. Approximately 15 percent of thetotal barrios can be reached only by walking.Only about 25 percent of the barrios have trans-portation within distances of 10 kilometers.
In addition, by tradition and custom, cul-tural minorities are intolerant of civil registra-tion practices.
REMEDIES TO UNDERREGISTRATION
Several recommendations have been madefor improving the completeness of registration.
The Administration
‘ Local officials are required to appropriatefunds for civil registry work.
Municipal and city councils are requested torevoke ordinances imposing fees for delayed reg-istration of births, deaths, and marriages. Theyhave to strictly adhere to the repealing clause ofPresidential Decree 651 which provides for therepeal of city/municipal ordinances imposingfees and fines on civil registration even whenmade within the prescribed period.
Certificates of birth, death, and fetal deathare distributed free of charge to needy munici-palities.
Local Level
Efforts are made to enforce a uniform inter-pretation of the laws pertaining to civil registra-tion, as it is the only way to obtain complete,
comparable, current, and accurate records ofvital events.
Provincial censu: officers, municipal censusofficers, and census assistants are to follow upthose monthly civil registry reports that are de-linquent.
As long as the local civil registrars are of-ficials acting in ex-officio capacity, a closer linkbetween municipal officers and the Civil Regis-trar-General should be established for closersupervision of local civil registrars. Furthermore,local civil registrars should be given incentives inthe form of some remuneration.
As soon as possible, regular or special localcivil registrars should be appointed. The officeof the local civil registrar should be convertedinto a full-time job and not be occupied by aperson holding another office (municipal treas-urer or city health officer) who has no time forthe job. The separation of duties and responsibil-ities of the local civil registrars from those of themunicipal treasurers or city health officerswould allow the former not only to do theirduties accurately but also to institute their owninvestigation and registration campaign in out-lying barrios.
The barrio captains must be fully involved inthe development and maintenance of a civil reg-istration system, in conformity with Section 7of Presidential Decree 651 enlisting their assist-ance in the registration of births and deaths.
The assistance of qualified residents of thebarrio should also be sought. In this respect, the“volunteers” envisaged in the frame of the Re-structure Health Care Delivery System couldplay a useful role which should be discussedwith the Project Management Staff Unit. How-ever, experience has shown that, to obtain theservices of efficient collaborators, wages or in-centives have to be paid for services rendered.
Close supervision through frequent field in-spection by members of the central staff andextensive communication between field and of-fice are required to ensure quality of collectedinformation. Supervision will help to clarifyproblem situations immediately or to discoverincomplete or unclear information. To remedymistakes or omission committed in the field isdifficult; to do so from the central office is al-most impossible.
79
Population Level
Presidential Decree 651 must be well publi-cized and reminders of this Decree should beregularly made so that the public will know itsresponsibilities, duties, and liabilities for failureto register births.
Posters, pamphlets, and brochures on civilregistration are to be printed and distributed.
A sustained educational campaign should beconducted through seminars on civil registrationwith the collaboration of regional/provincial/municipal census officers and munici-
pal assistants, local civil registrars and theirassistants, with medical personnel, hospitalclerks, nurses, midwives, teachers, parents,barangay chairmen/barrio captains and hilots asparticipants.
The Government and private hospitals, ma-ternity clinics, and health centers are earnestlyrequested to help and cooperate in the registra-tion of births and deaths they attend.
Church leaders are requested to help andcooperate in informing those concerned to reg-ister unregistered births of children baptized andmarriages solemnized in their churches.
REFERENCES
I National cen~u~ and statistics Office: Manual ofCivil Re@”stration. Manila. Office of the Civil Registrar-General, 1975.
2Nationa1 Economic and Development Authorityand National Census and Statistics Office: PhilippineYearbook, 1975. Manila. National Economic and De-velopment Authority and National Census and StatisticsOffice, 1976.
3Nat.ional Census and Statistics Office: Proceedings
of the CSvil Registration Seminar. Manila. Commissionon Population, Population Center Foundation, 1976.
4Mijaes, T. A.: Development and Maintenance of aSample Vital Regktration System in the Philippines. In-ternal Program of Laboratories for Population Statistics.Reprint Series No. 19. Chapel Hill, N.C. The Universityof North Carolina at Chapel Hill, Nov. 1977.
so
APPENDIX
CONTENTS
FormsReproduction of Certificate of Live Birth ............................................................................................ 82Reproduction of Certificate of Death .................................................................................................. 83Reproduction of Certificate of Feti Death ......................................................................................... 84Reproduction of Certificate ofa Foundlkg ......................................................................................... 85Reproduction of Mmiage Con&act ...................... ............................................................................... 86
81
APPENDIX
Reproduction of Certificate of Live Birth
MUNICIPAL FORM No. 102-(Revised Dec. 1, 1958) (TO BE ACCOMPLISHEDINDUPLICATE)REPUBLIC OF THE PHILIPPINES
CERTIFICATE OF LIVE BIRTH(FILL OUT COMPLETELY,ACCURATELY,LEGIBLYININKOR TYPEWRITER)
Register Number:Province: ........... ..... .... ......... ........... ............ .............. .......... .... ........... ... ........... . (a) CivifRegistrar-GenerdlN<>...,,.,...,,.........,,,,,.,.....,.,,......,.,.,,,..
City OrAiutlicipulity : .. .... ...... ... .......... .......... ........... .. .......... .... .............. .......... .. (b) Local Civil Registrar No . ..... .......... .... .... .... .... ................ .... ...
1. Place of Birth 2, usual Residence of Mother (where dots mother live?)
a. Province a. Province
b. City or Municipality b. City or Municipality
I
c. Name of Hospital or Institution (If not in hospital, give street c. Number and Streetaddress)
cf. is Placcof Birth hrsidc City Limits? I d.ls Residcncelmidc City Limits? lc, IsResidcnccona Farm?
Yes ❑ No ❑ Yes •l No ❑ I Yes•1 No ❑
CJ 3. Namc(Typc of print) Fkst Middle Last
~ j 4. Sex I 5~. This Birth ISb. lfTwinor TripJct, was Child I 6. Datcof Birth
Single •l Twin ❑ Triplet ❑ I 1st •1 2nd-”U 3rd •l I Month
~ 7.Name 1 First Middle Last Religion 8. Nationalityd ‘y +ia I I Ix
1
9, Age(Attimcof 10. Birthplace lld, Usual Occupation 116. Kindof Busincssorhrdustry~ this birth)
_{ Years I I.+ ~1’2. MaidcnName F!rst h4ddlc Last Religion 13. Nationality 13,!. Rscc
1~ 14. Agc(At timeof 1s. Bkthplacc 16, Previous DelivcriesofMorhcr
2 this birth) (Donol includethis birth)Years
a. How many b. Howmanyothcr c. Howmanyfctal17a. Informant’s Signature: children are children were deaths (fetuses
b, Namcin Print: now living? born alive but born dead anyarc now dead? time after cOn-
C. Address: I I ccption)?
18. Mother’s Mailiig Address: (Number, Street, City or Municipality, Province)
.19. ATTENDANT AT BIRTH
I HEREBY CERTIFY that 1attended the buth of this child who wasborn alive at o’clock _.M. on the date above indicated.
a. S18nature:b, Name in Pcirrt:c. Address:
20. Received in the Office of the Local Civil Registrar by:
d. Date Signed by Attendant at Birth:
e. I@ of Attendant at Birth:❑ M.D. ❑ Mldwifc❑ Nurse Cl Others (Specify)
21. ‘I. Given Name Added from Supplemental Report:
a, Signature:b. Name in Print: b. Date When Given Name was Supplied:c. Tide or Position:d. Date:
22cs. Length of Pregnancy 22b. Weight at Birth 23, Legitimate
Completed Weeks. Lbs. oz. 0 Yes a Nn
24. Date and Place of Marriage of Parents (For legitimate birth) I 25. This Certitkatc is Prepared by:
Signature:(Month) (Date) (Year) Name in Print:
Title or Position:
City or Municipality , Province _ I mtc:
18—2S9 (SPACE”FORMEDICAL AND-HEALTH ITEMS FOR-SPECIAL puRPOSEs)
NOT FOR SALEFROM THE CIVIL REGISTRAR GENERAL
.
Reproductionof Certificateof Death
h@dCipd Form No. 103-(RtdsedJarmmy, 1959) (To be accomphhed in duplicate)
RSPUBLfC OF THB PHIUPPINES
CERTIFICATE OF DEATHFILL OUT COMPLBTRLY, ACCURATELY, AND LEGIBLY WITH INK OR TYPEWRITER
RcgfrtcrNumber:R&nc& ..........................................................................................."..... (.) CM1RegMrar-GencralNo. .......................................................
Cftj or Municlpdky ................................................................................ (b) Local Cid RegfctrarNo. ..........................................................
10 Place of Death 2. Usuaf Reai&nce (Wb@gncd lived. If institution: reddmce btfore
& Province a Rovfnce
b. CiLYor Town c. Length of Stay b. City or Town
d, Ftd Name of Hoapkaf or Institution [If in ho:pkd or tnctitution) c. Ad&eu Street or BarrioI
3. Name of Deceawad a First b, Middle e. Ln$t(2ypaOrprfnt)
4. Date of Death:(Month) (Day) (Year)
5. sax 6. flaw 7. Married; Never Mamiad; 8. Date of Birth 9. ASe If Undm 1 Year If Undm 24 Hours
Wfdowed; Divorced or (Yea) (Months) (Days) (Hours) (Minutes)
Separated (Spccffy)
10. a, Uwl 02cupaH0n 10. b. GiveSpecific Businen 11. Birthplace (Phflfppines or foreign counuy) 12. Citizen of What Country
(Stat6 nature -d or Industry a. City or Town
chatacter) b. province
13. Father’s Name (Wcfte pltfnly io fufl) 14, Mother’t Maf&n Name (Write plaidy in fd)
15, If Mudtd, Name ad Ad&mc of Surviving SpouJC 16. Infornww ~ \~e~~t),.
17, C2wa of DA
Bnter only one causepar line(a), @) and (c).
l$b does not mean the modeof dyfo~ sorb w hew fdf-uce, aathenia; etc. It matthe dfwae, injury, or compff-catfon W&b caused. death.
I& Data of Operatfon
‘w, My:: (spccf@)
Homfclde
2(M+Time of Injury (Month)
c. (Addrcu) “d. (Relation to demaaed)
MEDICAL CER’ITFICATE I Intcrvaf Between
L &ease or Cadidon Directly Ledingto Death:*
ANTECEDENT CAUSES (a)
Morbid conditions, ff any, .giviugdat to the Am cause (a) stating
DIMto (b)
the underlying cauze last. Dlm to (c)
IL Other Signihnt CaWiOns-Conditiom contributing to the
&di but not dated to thedkcaae or condftfon +wing
Ionsetand wth
I19. Autopsy
Yes 13 No❑(Findings st the back)
&atb. I
18b. Msjor Findings of Opration
20b. Placeof Injury 20c. (Town or Street) (city) (Rovince)
(e.g. in or about home,
facm, fwtocy, Stteet,oftlce, bddfng, etc.)
—M I Work •l at Work •l I
21.1 hereby certify that the foregoing pattkcuk are comect u near as the same can be aatertaincd, and I further ctrtify that I bawinot attended thedacmmd from .......................................... ...................................., 19 ......... to ............................................................................. ................ , 19 ............
that +atb occurred at .....................................................from the cawes and on the &te stattd above.
22@) CC&f$ed comtct by; 22@)
•l RI-to Physkfan(signature) ...................................................................................................................................................
❑ Publfc Hedtb Offfmr(Fdf name in printed letters) ...............................................................................................................................
(Add+ .............................................................................................................................................................
•l Hotpkaf authotidet (Date) .,,,,,,. !!........0............................................................ ...............................................................................
23cr. Budal, (k.rmation, 23b. Date 2%. Name of Cemetery or Crematory
[
23d. I.ucufon Province (City, town)
Rtmoval (Specffy)1 ,
24 Date Rccchd by 240. R@stru’s Sfgnature (N811Kin pdnt) 24b. Bud Pemdt No. Issued on
Lmxl CfvIIRegis- Tmndr Permit No. Issued on
*UBy
l*22a NOT FOR SALEFROM THS CML REGISTRAR GRNE~
Ss
Reproduction of Certificate of Fetal Death
MUNICIPAL FORM NO. 103-A-(Revised Jmsuary, 1958)REPUBLIC OF THEPHILIPPINES
CERTIFICATE OF FETAL DEATH
(To be accomplished in Duplicate)
Register number:Provillcc: (u) Civi/RegiwmGr?nerdNo.
City or Mutticipdity: (b) Locdf Civi/Rcgisttar No.
1. Pkaceof Delivery 2. Usuid Residence of Mothcr(Where doesmothcr live?)a. Province d. Province
b. Cityor Town b. Cttyot Town
c. Full Namcof Hospital or Institution (lfnotin hospital orinstituticm, c. Street Addressgive street address or location).
3. Namcof Fetus (Ifeivcri) 4. Sexof Fetus.“.
., Male~ Female Cl Undetermined Ill
5m This Delivery 5b. lfTwinor Triplec, wasthis Fetus 6, Dateof Delivery (Month) (Day) (Year)Delivered
Single Cl . Twin ❑ Triplet ~ 1st •1 2nd •l 3rd •l I7. Name d, (Pirst) b. (Middle) d, (Last) % Nationality b. Race
Father1
9, Age (At time 10. Birthphtcc llIs. Usual Occupation Ilb. Kindof Busiriess orlndustryof delivery)
I — Years I12. Maiden ,1. (First) b. (Mtddle) e. (Last) 13tr. Natiomdity b. Race
I
Mother 14. Age(Attimc 15. Bhthplace 16. Previous Deliveries roMother (DO NOTinclude this fetus). ofdclivery) a. How many I b. How manY I c. How many Previous
I ---.-L Years childretr are now children were born fetal deaths ~fetutes17. Informants Signature “ living? alive but ate now born dead at Any time
Name in Print dearl? after conception ?)_/18u, Length of Preg- 18b, Weight of Fetus 19. Legitimate 20. When Did Fetus Dle 21, Autopsy
nancy Compleccd Before During bbor Un-
— Weeks _ Lb. _Oz. Yes ❑ No ❑ Labor •l or Dehvery El known Cl Yes ❑ No ❑
22.
Causeof
Fc.tai
1. Direct and Antecedent CausesDiect Cause
State fecal or maternal condition directlycausing fetal death (do not use such termsas stillbirth or prematurity) I
Antecedent Cau*esState fetal and/or maternal condition, ifany Giving Rise to the Above Cause(ta) stating the Underlying Cause I
(enter cmly one cause pet line)
(a)
Due to
(b)
Due to
Last. . 1 [c)
11. Other significant Ccmditions of fetus or mother which may hwe Contributed to fetal death, but, in so far is known, were not relatedto dir~kt causeof’ fetal death.
I7
I hereby certify that 23a, Attendant’s Sigrtarure 23d. Dme Signed
this delivery occurred on”the date stated above andthe fetus was born dead (Name in Print) (Specify if M.D., Nurse, midwife, or other)at _ o’clock—m. 23C, Attendants Addre$s II If not attended I 24. Signature of City or Municipal Health Officer
by physicianName and Tide in Print
25a. Busia\, Cremation 25b. Date 25c. Name of Cemetery or Crematory 25d. Location (City, town or street) (Province)
I I I26, Funeral Director Address Date Received by Registrar’s Signature
Local Regfstrai
(Name in Psint)
a4
Reproduction of Certificate of a Foundling
CRG FORM NO. 101 (New Form ~evised November, 1959)
CERTIFICATE OF A FOUNDLING(To be accomplished in duplicate)
Province ! CRG Registry No.
City/Municipality: LCR Registry No.
1.
3.
4.
6.
7.
9.
Name of the child: 2. Sex:
Approximate Age of the Child when found:
Color of Hair of the Child: 5. Color of the Eyes of Child
Place the Child was found: ,.
Date the Child was found: 8. Time the Child was found:
Distinguishing features and/or marks in the child:
10. THIS 1STO CERTIFY; that the information given above are true and correct to my own knowledge and belief.
a. Informant’s signature:
b. Informant’s name in print:
c. Informant’s address:
11. Name of Notary Public or officer who administered the oath to the affiant in the sworn statement declaring the finding of the chdd:
12. Notarial identification of the sworn statement declaring the Finding of the child: Docket No. Page No. _
Book No. _ Series of 19 _
13. Date reported to the local civil registrar:
14. a. Signature of the local civil registrar:
b, Signature of the local civil registrar in print:
NOTE: THIS CERTIFICATE MUST BE FILED WITH THE SWORN DECLARATION OF THE FINDING OF THE CHILD.
llce
85
Reproduction of Marriage Certificate
MUNICIPAL FORM No. 97-(FOm No. 13)REGISTER NO. ........................ ......
MARRIAGE CONTRACT
HUSBAND
Contracting Parties .......................................... ........................................... .. ........................................................
(u) Age ................................................................................................. ....................... ... .............................4
(b) Nationality .#........................................................t.......................... ........................................................
(c) Residence ...... .........4....................................................................... ..... ...................................................
Single, widowed or divorced ........................................................................ ........................................................
Father .................................. .......... .................................... ........................ .. ........................ ................................
Nationality ...................................... ............................ .......................... ................................ ........................
Mother ......................................................................................................... .............. .................. .......................
Nationabty .............................. .... ................................. ......................... ........................................................
Wltncsses ..................... ...... ............................... ............................................ ........................................................
Residence ........................... ................................................................... ............................. ..........................
Persons who gave consent or advice .... ......................................................... ................... ................................ ....
(rI) Residence ..................i....................................... ............................. .......................................................
(b) Relation to contracting party ......................................... ................ .......................................................
4
WIFE
.......................................................
........................................................
........................................................
........................................................
........................................................
.................................. .....................
, Officeof fhc )
‘kceofmarriag’!:~:f1"""""""""""""""""""""""""""""""""""""""
(a) .. . .. . .. . . .. . .. . .. . .. . .. . . .. . .. . . .. . .. . .. . . ..iFi.K..r . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (b) ................................ ............7Aii.kr.................................................
THIS IS TO CERTIFY: Thatr, .................................................................................................................................................. .................... .. and
I., ..................................................................................................... ....................... ........ on the dute and at the place above given, of our o wn free will
and accord, and in the presence of the person solemnizing this marriage and of the tivv witnesses named beb w, both of age, take ●ach other ai
husband and wfc,
And I,... .. .. .................................. .. ........................................ ............................... . ...................... .................... .................... .................... ................(Position)
CERTIFY: That on thedate artdatthe place above writterc the aforesaid ..............................o......................... ..........................................................
and ............................................................... ........................................................................... werewith theirmuttmfconsentbcwfullyjoinedtcyether
in holy matrimony by me in thepresence ofsaid witnesses, both ofage; and Ifurther certify that the Marriage Licercse No. .........................................,
issccedat .. .................................................... ............................. ........................................... on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . 19..........
in favor of said parties, wm exhibited to me or no man-kge license was exhibited to me, this mwriage being ofanexceptional character performed
under Art. .............................. of Rep. Act 386; and that consent or advice to such marriage was duly giveri, as required by law, by the person or
persons above mentioned.
IN WITNESS WHEREOF, we si@aed, (or marked with our fingerprirct) this certificate in triphcate this ................. d~y of ....................................
19........ .
............................................................................................. ..............................................................................................(Contracting Party) (Contracting Party)
.............................................................................................(Judge, Justice of the Peace, Mayor, Vrie$t, Mini%t.r, etc.)
WITNESSES
Analysisof Vital Statistics
Services in Thailand
Dr. Fredhold and MS Kuhner
World Health Organization Study Mission to ThailandMarch 7-27, 1977
CONTENTS
Introduction ............................................................................................................................................. 91General kfomation ............................................................................................................................ 91
Organization of Civil Registration and Vital Statistics ............................................................................... 92Ministry of the Intefior ........................................................................................................................ 92Nationaf Statistical Office .................................................................................................................... 92Ministry of Public Health ............................................................ ......................................................... 92
Re@stition @rtificates ............................................................................................................................ 93Routing .............................0................................................................................................................. 93Birth Certificate ................................................................................................................................... 95Death Cetiificate ................................................................................................................................. 97Stillbirth Certificate ............................................................................................................................. 99
Processing, Tabuktion, ad Pubhcation of Wtilmd Hedti Statistics ...................................................... 99
Evacuation .................................................................................................. ............................................... 99Early Surveys ....................................................................................................................................... 99National Statisticrd Office Surveys ....................................................................................................... 100b&viduA Items ................................................................................................................................... 101
hproving the System ............. .................................................................................................................. 101The Wpmg Health Development Project .......................................................................................... 101Community Self-Reliance .................................................................................................................... 102Health Planning and Management Information System .............................................................. .......... 103
Recommendations ..............................~..................................................................................................... 105
References ................................................................................................................................................ 106
Appendix: Forms ..................................................................................................................................... 107
LIST OF FIGURES
IV-1. Organization of health services in Thailand ..................................................................................... 93
IV-2. The vital registration reporting system in Thailand-births and deaths ............................................ 94
LIST OF TABLES
IV-1. Comparison between items included on Thai birth certificates and intemationaf standards ............ 96
IV-2. Comparison between items included on Thai death certificates and international standards ........... 97
IV-3. Comparison between items included on Thai fetal death certificates and international standards ... 98
IV-4. Estimated completeness rates of bwth and death registration by 5-year groups, 1961-69 ................ 100
IV-5. Estimated completeness rates of death registration, by sex and age ................................................ 100
89
CHAPTER IV
ANALYSIS OF VITAL STATISTICS
SERVICES IN THAILAND
Dr. Fred Arnold and Alois Kfiner
INTRODUCTION
General Information
The Kingdom of Thailand, formerly knownas Siam, is located in Southeast Asia. It has an
area of about 200,000 square miles. Thailandhas common boundaries with Burma on the westand northwest, Laos on the north and east,Cambodia on the southeast, and Malaysia on thesouth.
Thailand’s topography is diversified withfour main geographic regions-central, northeast,north, and south. The central region is domi-nated by Thailand’s most important river, theChao Phaya. The land is rich in alluvium andwatered by an extensive network of canals andirrigation projects. The northeast region, a largeplateau rising about 1,000 feet above the centralplain, comprises roughly one-third of the coun-try. Most of this land is poor and suffers eitherfrom occasional droughts or floods dependingon the season. The topography of the plateaumakes irrigation difficult, but planned irrigationand flood control projects on the Mekong Rivershould improve agricultural potential.
Northern Thailand, a region primarily ofmountains and valleys, comprises about one-
quarter of the Nation, The mountains, extendingnorth and south, are forested; the valleys be-tween them are narrow but fertile.
The southern region, along fragment of landstretching from ,central Thailand southward toMalaysia, is greatly covered by rain forest.
Thailand is a tropical land, high in tempera-
ture and humidity. The climate of much of thecountry is dominated by monsoons. In mostregions three seasons prevail: rainy (June-October), cool (November-February), and hot(March-May). Rainfall varies, but is generallyheaviest in the south and lightest in the north-east.
Thailand’s most important administrativedivisions are the 71 Provinces. Each Province isheaded by a Governor, who is an appointedofficial responsible to the Minister of Interior.Elected provincial assemblies enact local gover-nmentordinances.
T’he 71 Provinces (changwats), including theBangkok Metropolitan Area, are further subdi-vided into over 530 districts (amphoes), 5,000communes (tambols), and about 50,000 villages.
The head of the district (district officer) isan appointed Government official who is re-sponsible to the Governor. The village headmanis elected by the population. The village head-men of one commune elect the tambol headmanwho, in turn, is responsible to the districtofficer.
Waterways carry more than half of Thai-land’s freight. The waterways are supplemented
by a state railway system.In the mid-1960’s there were approximately
6,500 miles of highway. Well-built roads exist.Most roads serve as connections between therailways and waterways. Domestic airline serviceis maintained by the Government’s Thai Airways
91
Co., Ltd., with airports at most provincialcenters. Internal mail service uses railroads andairplanes to serve the country. Telegraph servicereaches only principal commercial and railwaycenters. Radiotelegraphy is used largely for Gov-ernment messages; the Government owns andoperates the radio network. Two television sta-tions exist, one is operated by the Ministry of.Defense and the other is operated by a semi-governmental cofioration. Telephones arescarce.
Thailand’s population of about 46,200,000(1979 estimate) is composed primarily of peopleof Thai stock. The principal minority groups areabout 2 million ethnic Chinese located mainly inthe larger urban areas, most of whom have inte-grated into the Thai society; over 800,000Malay-speaking Moslems in the southernmostprovinces; about 300,000 various hill tribes inthe north; and over 50,000 Vietnamese, mostlyin the northeast.
Thai society is predominantly rural and isheavily concentrated in the valleys and plains ofthe north, northeast, and central regions.
ORGANIZATION OF CIVILREGISTRATION ANDVITAL STATISTICS
Three major Government agencies are in-volved in civil registration and in the productionand use of vital statistics: the Ministry of theInterior, the National Statistical Office, and theMinistry of Public Health.
Ministry of the Interior
The People’s Registration Act of 1956 stipu-lates the establishment and maintenance ofpopulation registers in all amphoes and tambols. ~The tambol registrar, generally called the“kamnan,” and the municipal registrar workunder the authority of the Ministry of the In-terior. The kamnan keeps the original register; acopy of all birth, death, and fetal death certifi-cates is kept by the amphoe registrar.
According to the Registration Act, the headof the household is required to notify thekamnan of any vital event occurring in his house-
hold; the kamnan then issues the various certifi-cates, after he verifies the vital event.
The district and provincial offices send tothe Ministry of the Interior summaries of infor-mation on population size according to sex onceevery month. This information is kept by theMinistry and is not further analyzed. At the endof each year the population figures are publishedby the Ministry, with a delay of only about 3months.
National Statistical Office
In the area of civil registration and vital sta-tistics, the work of the National Statistical Of-fice is limited to conducting population cen-suses, speciaI population surveys, and analyses.In this regard, the National Statistical Office is amost important user of primary vital statistics—not a producer.
This Office is also responsible for the overallcoordination and, improvement of statistics inThailand. Within the scope of this objective, theNational Statistical Office has conducted twomajor national surveys to estimate vital rates andevaluate the completeness of vital registrationand statistics. The results of these surveys will bediscussed later in this chapter.
Ministry of Public Health
The health services of Thailand at all levelsperform very significant functions in the regis-tration of vital events and in the analysis andpublication of vitaI statistics.
The structure of the health services differs inonly minor aspects from the general administra-tive organization of the country.
The organization chart (figure IV-1 ) showsthat the overall responsibility for public health,inchding preventive health services, lies with theMinistry of Public Health. Each of the Provincesas well as the Bangkok Metropolis an Area isunder the jurisdiction of a provincial chief medi-cal officer who generally supervises:
6 The provincial hospital (with a large out-patient capacity).
. The district health offices and rural andme&lcal health centers (MD’s, nurses, mid-wives, sanitarians).
92
cepts the responsibility of registration. In the
I
PROVINCIAL Office of the provincial Provincial(CHANGWATI LEVEL chief mwflcd officer hospital
I
——J———— “—DISTRICT I h-~h.ffi.,r~ ~f$:::::sIOffice of the district
(AMPHOE) LEVEL
I 1
CoMM”NEw(TAMBOL) LEVEL
VILLAGELEVEL I Midwifery
cmters I, 1
Figure IV-I. Organization of health services in Thailand
The health subcenters at the tambol level(one midwife, one sanitaria).
The midwifery centers at the village levelstaffed by a m“idwife prov@ing m~ly ma-ternal and child health (MCH) services.
REGISTRATION CERTIFICATES!’
In 1909, the registration of live births anddeaths was started in the Bangkok area; and in1916, birth and death registration was mademandatory throughout” Thailand. Fetal deaths(stillbirths) were included in the registrationsystem in 1936. Until recently, fetal deaths wereregistered by attaching a birth and death certifi-cate together and marking them as a fetal death,but a special fetal death (stillbirth) form is nowin use for the registration of stillbirths. The cur-rent procedures for registering vital events aregoverned by the People’s Registration Act of1956 which has been expanded since that time.
By law, births must be registered within 15days of their occurrence, and deaths and still- ‘births within 24 hours. The head of a householdor the mother of a baby “isresponsible for seeing -that a birth is registered. For stillbirths, the re-———
Zponsibility lies with the head of the householdexcept when the delivery occurs outside of anyhouse or hospital, in which case the mother ac-
c&e of death:, registration is‘the responsibilityof the head of the household or of the personwho finds the body.
Registration of births, deaths, and stillbirthsis on a de facto basis, that is, according to theplace of occurrence of the event rather than theusual place of residence of the mother or thedecedent.
Routing
Registration forms for births, deaths, andstillbirths consist of three parts for each type ofform (see appendix, “Forms”). In each case,parts 1, 2, and 3 are identical except that part 3contains additional information. On registration,part 1 is given to the person who registers theevent; it constitutes the official certificate of theevent. The disposition of parts 2 and 3 dependson the place in which the event occurs. The de-tailed routing of the certificates is shown in theflowchart in figure IV-2.
There is no charge for registering a birth,death, or stillbirth if it is registered within thelegal registration period. In the case of late regis-tration, the registrar may assess a fine of up to200 baht (approximately U.S. $10); the fines,however, are often of nominal amount or elsewaived completely.
Births and deaths that are reported to theregistrar are recorded as additions or deletions tothe household register as well as being recorded Ion the birth and death certificate forms. A copyof the household register is kept by each family.The House Registration Form used for this pur-pose is shown in the appendix.
Rural areas.–In nonmunicipal areas, where85 percent of the population lives, vital eventsare registered at the tambol level “with thekamnan. The average commune comprises about10 villages. The kamnan serves as the officialregistrar for the commune, but he has manyother duties as the government’s commune rep-resentative. He returns part 1 of the certificateto the informant and sends parts 2 and 3 plus asummary report to the arnphoe on the 5th ofevery month. In special cases, such as when theinformant cannot contact the kamnan withinthe legal time limits, vital events may be regis-tered directly at the district office. Part 2 of the
93
NONMUNICIPAL AREAS MUNICIPAL AREAS OUTSIDE BANGKOK METROPOLIS BANGKOK METROFULIS
Nonhwpital events HospiM events Nonhospifd e’mnts Hospital events
PIEvent regimered
imwm!r%d-mrn)
PA 1 Parts 2&d3and
Icom mum, mmmcry
Pat 3 and dl~ct summary
p~,+q
Part 3 and munbipd summary
Notifhion P&1
form and change
I of addres$
Part ~ anddistrict symmary
P.m+ ,.
BangkokMetropolitan
Administmtion
Part 3 andsummary wmmary rewrt
Ministry ofthe Interior
t
rpam3a””mmawr”””
SummaryreDOl-t
Figure IV-2. The vitel registration reporting system in Thailend-births and deaths
certificate is stored at the arnphoe and part 3 issent to the provincial chief medical officerthrough the Governor, and a district summary ispassed along to the provincial office on the 15thof each month. Up to this point, the registrationprocess is entirely under the control of the Min-istry of the Interior. At the provincial level, theGovernor’s office makes a summary report tothe Ministry of the Interior in Bangkok, but theMh-iistry of the Interior does not receive the ac-tual certificates. Once part 3 of the certificate isturned over to the provincial chief medical of-ficer, control of the certificates shifts to theMinistry of Public Health. The provincial chiefmedical officer checks the certificates for com-pleteness and accuracy, paying special attentionto the cause of death on death and stillbirthcertificates. On the 25th of the month followingreceipt of the forms, the provincial chief medical
‘ officer is required to send a summary report pluspart 3 of all certificates received to the Ministryof Public Health in Bangkok for processing andpublication. This is the general procedure forregistration, although the practice may differslightly from one area to another and delays areoften encountered in meeting the schedule.
Municipal areas.–Registration proceduresare similar in municipal areas except that eventsare initially registered at a slightly higher ad-ministrative level. In municipal areas outside ofthe Bangkok Metropolis, births, deaths, and still-births are registered directly at the municipalityoffice. As always, part 1 of the certificate is re-turned to the informant. Part 2 is stored at themunicipality office and part 3 plus a municipalsummary is sent to the provincial office chang-wat. From there the documents follow the samecourse discussed earlier.
In the Bangkok Metropolis, events are regis-tered at the district office. Part 1 is returned tothe informant; part 2 is retained at the districtoffice; part 3 is sent to the Bangkok Metropoli-tan Administration. From there, part 3 plus asummary report goes directly to the Ministry ofPublic Health, and a separate summary reportgoes to the Ministry of the Interior.
For events that occur in a hospital, a notifi-cation form is filled out and sent to the districtoffice or the municipality office. These formsare the responsibility of the medical records of-ficer or other hospital personnel. In the larger
hospitals, the forms are normally delivered byhospital personnel on a daily basis. The notifica-tion forms contain most of the same informa-tion as the certificates of events, but there areminor differences. The registrar issues a certifi-cate for the event, returns part 1 to the informa-nt, and, in the case of births, also issues a formfor changing the baby’s address from the hospi’-tal to the usual place of residence. In some cases,hospital personnel will receive these forms fortransmittal to the mother or a relative at thehospital. In other cases, the mother of a new-born child will also be given a separate card ad-vising her to take the card to the district ormunicipality office in order to obtain the birthcertificate and the change of address form tochange the baby’s address from the hospital tothe place of usual residence. An example of thecard used for this purpose by ChukdongkornHospital in Bangkok is shown in the appendix.
Detailed information collected on birth,death, and stillbirth certificates basically con-forms to first-priority international standardsand includes many items from the second-prior-ity international recommendations as well (seetables IV-1, IV-2, and IV-3). In addition, theThai certificates include a large number of coun-try-specific items that do not appear in the inter-national recommendations.
Birth Certificate
The birth certificate contains items charac-teristic of the event itself (e.g., date and place ofoccurrence); demographic and physical charac-teristics of the child; fairly detailed characteris-tics of the parents; and information about theinformant and the attendant at birth. Informa-tion is also collected on any illness the mothermay have suffered due to pregnancy, delivery, orother factors. In alI cases, the baby’s name mustbe recorded at the time of registration no matterwho registers the birth. The name may then bechanged at any time within 6 months of theregistration date without charge. The birth cer-fi~e consists of three parts. Parts 1 and 2 arehalf a page long and contain identical informa-tion. Part 3 is a full page with the sameinformation as the previous parts on the top halfplus more detailed information on the bottomhalf. Carbon paper is used so that parts 1 and 2plus the top half of part 3 need to be filled out
95
Table IV-1. Comparison betwean items included on Thai birth certificates and international standards
Characteristic
Event
Date of occurrence .. ........ .......... .......... ...... .. .................... .. .. .................... .............. ............... ...Date of registration ..... ...... .... .... .... ...... ...... ................ .. ........ ...... .. .............. .. ........................... .Place of acurrence ........ .... ........ ........................... ..... ........ ........ ...................................... ..... ..Type of birth (single or multiple issue) . .................. ........ ........ ........ .... ................ .....................Type of attendent at titih ...... ...... .......... ............... ............... .................. ........ ...... ................. ..Name and address of attendant at birth ..... .. ................................ .... .. .............. ...... ............... ...Hospitalization ..... .................. ............ .......... ...... .. ...... ........ ........ .......... ...... ...... .... .. .................
Child
sex ..................... .. ........................... .......... ................. ............ ............... ........... ..... ..................Legitimacy status ............ ...... .......................................................... .......... .. .... ........ .... .... ........Weight at birth ........ ........ ....... ............... .. .... ... .. ........................... .............. .. .............. ....... .......Height at birth ................. ...... ..... .... ....... ............. .............. ........................... ....................... .. ...Gestational aga ................................ ...................................... ......... ................ ..................... .. ..Nationality ...... .. .......... ............ ................... ..................................... .......... ...... ................ ...... ..Injurad dua to delivary? ................................... ................ .......... ........ ........ ................. ..... .. .....Abnormal body ..... .. .......... ........ .. .......... .......... .......... ........ ........................ ..............................
Mother
Age ......................................................... .................... ................................ .............................Children born alive during mothar’s I ifatime .. .. .................................... ................................ ...Children still living ..... ................................. ........ ....... ........... ................. ........ ...... .. ........ .........Fetak deaths during mother’s lifetime .................... .................. ......................................... .......Number of children born alive who died ................... ................... .............. ............... ..............Birth order ................................................. ................ .......... ................ .. .................... .............Interval since last pravious live Mrth ........... ........... .................. ....... ....... ......... ....... ..... .............Duration of marriage .................. .......... .. ........ .. ........... ...... ........................ ....................... .... .. .Education attainment ..... .... .... .... .... .. ...... .. .... ................ ......... ........... ...................... .... .............Literacy status ...................... .............. .............. .... ............................................ .......................Ethnic group ............... .......... .... ........ ............... ........................... ................ .... ................ ........Religion ...... .. ................................. .. ...... ..................... ............... ............ .... ............ .... ..............Citizenship ...................................... .......... ............. ......... ........ .......... .... ......... .........................Type of economic activity ... .. .......... ............ ........... ........ ............. .... .......... .. ................ ..... ..... ..
Occupation ... ...... .. .......... .. .......... ........ ............ .... ........ ................ ........ .... .... .... ...... ...................Placa of usual residence .... .......... .. .................. .. .......... .......................................... ...... .............Duration of residence in usual (prasent) Place ....................... ......................... .. .................... ..-Place of residence at a specified time in the pest ................... .. ........ ..... ................. .. ................Place of ti~h ............. ............. ......... ...................... .......................... ........................... .............Illness of mother due to pregnancy .........................................................................................Illness of mother not due to pregnancy ......... ........ ............ ........ .. ........ ...... .......... .. .... ..............Illness of mother due to delivery .... .... ... ........... .......................... .......... ...... .... ........................ .Special delivery .............. .. .. ............. ............ .............. ............. ................................ .... .............
Father
Age ......... .... .. ...... ........ ........................ ............... ..... .......................... .......................................Educational attainment .......... .................... .... .................. .. ........ ........ ........ ................ ...... .......Literwy status ... .............. ........... .. ........ ............ ........... ................ ............... ..... .. ... .. .... .... .........Ethnic group .................... . .............. ...... .... ............ ................. .......... ...... .......... .......................Religion ....................... ........... ........................... .................... ......... ... ... .......... .........................Citizenship ......... ......... ........... ........ ............. ..................................... .......... .............................Type of economic activity ..... ................ ...... .. .............................. ...... .... .......................... ........Occupation ... ...... .. .. .... .... ........ ..... ......... .... ................ .......... ........ ................ ...................... .......Place of usual residanca .............. .......... .. ........... ......................... .......... ...................... .............Duration of residence in usual place ................ .......... ................................................. .............Place of residence at a specified time in the past .................. .... ... ... .. .......................... ..... ........Place of Mrth ............... ........................................... ................................... ..............................
Thailand
certificate
xxxxxx
xxxxxxxx
xxxxxx
xx
xx
xx
xxxxx
xx
xx
xx
x
‘irst prioritynternationalstanderds
xxxxx
xxx
xx
x
x
x
Expandedinternational
commendations
xxxxx
x
xxx
x
xxxxxx
xxxxxxx
xxxx
1xxxxx
NOTE: The international standards do not include information on registration number, place of registration, characteristics of the registrar,characteristic of the informant, or names of the principal people invoIved. Therefore, these items have not been included in the table.
Source of international standards: Reference 1.
96
Table IV-2. Comparison between items included on Thai death certificates and international standards
Characteristic
Event
Date of occurrence .......o.............o.............o.........o...........................o........................................Date of registration .................................................................................................................Plaoa of occurrence .........................................................$.......................................................CaUstrof death .,, ,,,.,.,.,,..., ,.,, ,,,. ,,.,. .,., .,!,. ,,., .,!!.,.! ......!......,,.. ,...:.,,.,.,,.,., ,,...,,. ...........................!Tvpe of certifier .0.,, .................................................................................................................Name and address of certifiar ,,.,,!,,,.,,,,,...,., ,,.., .,!,..,,,,,.,,, ,.,,,.,.,,.,,,,,.,.! ,,,..,, ,,.,,..,,.,.,., .......!!..,,..Attendant at birth (for daeths under 1 year of age) ................................................................Ilospitallzation ....o... ..................o..o..ot..e...................................................................................Major symptoms of illness .......................................................................................................Duration of illness ...................................................................................................................Disposal of the corpse ,,,,,..,,,.,.,,,,,,,,.,,..,,.,,,,,,.,,,,,..,...,,.,....,.....,.,,,,,,.,,..,...,,..,,..,,,,.,,.,,.,..,,......,Performance of autopsy ......................................+........o.............f.............................o..........$...
Decedent
Age.,, ...!.,, ,,. ,.,,,,,. ,..,.,,.,,,,, ... ,.,.,.,,, ,,,, ,.,, ..................,.......0....!.!,.............. .................................Age of surviving spouse (for married) ......................................................................................sex ,,,.,, .,.,.,,, ,,,, ,.,, ,,,, ..!...!,,,,,.,,. ,..!.,.,,..,!,,..,,, .,..!..,,.,,,.,,,,,, ,,.. ,...,, .!,... !,,.., .,,, ,,..,,.,.!,..,.,.. !..........!Merital status...........................................................................................................................Duratirrn of marriage ...............................................................................................................Children born alive (for females of childbearing age and over) ................................................Children still living (for females of childbearing age and over) .................................................Educational attainment ...........................................................................................................Literacy status ...................1........o...................................o.......oo...............................................Ethnic wou~ ...........................................................................................................................Rellgio; ...................................................................................................................................Citizenship ..............................................................................................................................Was birth registered? (for deaths undar 1 year of age) .............................................................Legitimacy status (for deaths under 1 year of age) ..................................................................Type of economic activity .......................................................................................................~cupation .............................................. ................................................................................Place of usuel residence ...........................................................................................................Place of residence at a spacified tima in the past .....................................................................Plaoa of birth .................................................................................................................!.........Duration of stay at place of death ..................................,.. !...............................,... !...?.,,.... ,...,,
Decedent’s parents
Father’s citizenship .................................................................................................................Mother’s citizenship ................................................................................................................Fathsk’s plaae of birth ........................................................................................O....................Mother’s pleoe of birth .................!....!.,.,.,..,.. ...............................!.! ........................................Father'$ occupation,,,,,,,,.,,.,.,,.,.,..,.,,....,.,,.,,,..,.,,..,,,.,...,,....,,,,,,,,..,.,....,...,,......,.......,......,...,,...Mother’s uoupation ................................................................................................................
Thailanddeath
certificate
.xxxxxx
xxxx
x
xx
x
xx
xx
xx
xxxxxx
First Rriorityinternational
etandar&’
xxxxx
x
xx
x
Expandedinternational
xxxxx
xx
xxxxxxxxxx
xxxxxxxx
NOTE: The brternntirrnal standards do not include information on registration number, place of registration, characteristics of the registrar,characteristics of the informtmt, or names of the principal people involved. Therefore, the= item$ have not been included in the table,
Source of international stondards: Reference 1.
only once, The detailed information in part 3 islikely to be less completely filled out than theother parts, particularly if the birth occursoutside of a hospital or if the informant is notthe baby’s mother or father.
Death Certificate
The death certificate contains items charaoteristic of the event itself, detailed characteris-
tics of the decedent, some characteristics of thedecedent’s parents, and information about theinformant and the certifier of the death. Thecause of death is recorded and coded accordingto the International Classification of Diseases,1965 Revision. The death certificate also con-tains information about whether an autopsy wasperformed and how the body was disposed of.The three.part format is similar to that just de-scribed for birth certificates.
97
Table IV-3. Comparisonbetween items included on Thai fetal deeth certificates and international standards
Characteristic
Event
Dete of occurrence (of fetel &livery ).... .................................. ............................. .. ............. .. ..Date of registration .......... ........................... ................................ ............................................Piece of occurrence .............. .................. .................................... .............................................Type of birth (singleor multiple i~ue) ... .............................. ........ ...................................... .... .Attendent at birth .......................... ......... ............................................................. .. .... ..... ....... .Type of certifier .... .................... .. .......................................... .......................... ...................... ..Neme and address of certifier ......................................................... ...................................... ...Cause of fetal &ath .... .... ......................................... ......................... .................... ...................Time of death (in relation to delivery) ....... ..................... .... ...................................... .. ............Hospitalization ............... ............................ .................... .. .................. ... ........... .......... .............Method of delivery ..................................... ................................................ ............ ......... ........Autopsy performed? ...... .............. ........ ...... ........ .......... ...................... ........ .. .. .... ...... .. ...... .......Important symptoms (of mother and stillborn child) ................ ........ .. ............ ...... ................ ..Disposal of corpse ..................... ............ ...... .... ............ .......... .......................................... ........
Fetus
Legitimwy status ,!.. .... .... .. ............................... ............... ........................................................Weight at &liveW ............................... ................................ ............ ............ .......... ...................Height at delivary ..... ...... .... .. .. .... .... .. .......... ...... ...... ............ .. ........ .... .... .. ...... ......... ....... ...........Gestational age ........................ ......................... ......................... ...... ............ .... ........................Abnormal at tirth? ...................... ........................................ .......................................... .. ........Wounded due to &livery ?.............. .... .... .............. .............. ...................... .. .. .. .................. .... ...
Mother
AW ... ........... .... ............ .................... ........................ .... .... ...... ................ .... ........ ......................Children born alive during entire lifetime of mother .................................. .......... .. .............. ...Children still living .................. .......... ........................................................ ..............................Fetal deaths during entire lifetime of mother .................. ...... .... .... ........ ...................... .......... ..Total number of pregnancies ....................... ............ ..... ...................... ........ .. ......... ..... ........... ..Number of children born alive who died .................................... ........ ........ .. .............. .............Number of childran who died before 28 weeks .......... .............. ........ ................ .............. .. .. .... .Duration of marria@ ...... ...................... .................. .... .... ............................ ............ .................Educational attainment ...................... ........................................................ ..... ............ ............Literacy stitus ..... ....................................... ........... .......... ............ ....... ......... ............................Ethnic group ....... .... ........ .......................... .. .... .... ........ .... ...................... ..................................Religion ........... .... .................. .......... ........................ .................... .... .... ............ ........ ................Gtizanship ...................................... .. .... .... .. .. .... ........ .. .. .................................... .. .. ...... .. ..........Type of economic wtivity .......................... ....... ..................................... .... .............................
Placa.of usual residenca ...................... ................................... .... ............ ..... .... ............ .............Type of last pravious deiivery (singla or multiple) ....... .................. .. .. .... ................ .... .. .......... ..Outcoma of last previous delivery .. .. .. .... ...... .......................... ............ .... .. .. .... .... .... .... .............Date of last previous delivery ...................... .......... .......... ...... ........ ........ ..................................Oelivery order .......................... ....................... .. ................ ..................... ........ ............. ........ ....
Fathar
E~ucational attiinmmt ............... ........................ .. ........ .................. .......... ...... ........................Literacy smtus ..... ........ .... ...... .................. .... .................... ...... .............. .. ...... ............ ................Ethnic group .................................................... .............................. ............................ .............Religim .......... .................. ................................................ ......... ................. ............... ..............Citizenship ..... .............. ............ ................... ..... .......... ............................ ..... .... ........... .............Type of aconomic ectiviW ....................... ............................. ...................................................Ocwpation ............... ............................................................. .......... ............... ........................ .Place of usual r~i&nca ............................................................... ..................... .......................Plwa of birth .................................................. ................. ...... ..... ................... . .......................,
Thailand‘etel deathcertificate
xxxx
xxxx
xxxx
xxxxxxx
xxx
xxxxx
xx
xxxxxx
xx
xx
xxx
First priorityinternational
standards
xxxx
xx
x
xx
x
x
x
Exoendedinternational
racommandatlons
xxxxxx
x
x
xxx
x
xxxx
xxxx
xxxx
xxxx
xxxxx
NOTE: The international standards do not include information on registration number, place of registration, characteristics of the registrar,characteristics of the informant, or names of the principal people involved. Therefore, these items have not been included in the tuble.
Source of international standards: Reference 1.
Stillbirth Certificate
The stillbirth certificate contains many’ ofthe same items that appear on the birth certifi-cate and the death certificate. The certificate isdivided into only two parts, because no copy iskept at the district or municipality office.
PROCESSING, TABULATION, ANDPUBLICATION OF VITAL AND
HEALTH STATISTICS
In a previous section, it was pointed out thatvital registration data are collected by theMinistry of the Interior and the vital and healthstatistics division of the Ministry of PublicHealth. However, only the latter makes use ofthe information for further analysis, processing,and publication. This information is received atthe national level in the form of provincialsummaries by sex and age mid individual cer-tificates of birth, death, and stillbirth. Theseinformation sources are supplemented bymonthly reports on communicable diseases fromthe Division of Communicable Disease Controlof the Ministry of Public Health and theBangkok Metropolitan Area.
Although the individual certificates are usedonly to spot check the summary reports and forspecial studies mostly for’ internal dktributionwithin the Ministry of Public Health, the sum-mary reports serve as a basis for the preparationof numerous tables. The processing equipmentat present available to the Ministry of PublicHealth for these purposes, and rented fromInternational Business Machines (IBM), includes
“ three numeric card punchers (IBM-029), twoimmeric card verifiers (IBM-059), and one cardsorter (IBM-083).
Tabulation is done for a variety of purposesbut only a set of minimum standard tables ispublished in the annual Public Health Statisticsvolume. Unfortunately, there is at present adelay of about 3 years in publication of data.
The importance of vital statistics as a basisfor the statistics published in this volume isclearly shown; over 90 percent of the informa-tion published is based on data of vital events:number and rates of live births, infant deaths,
maternal deaths, and stillbirths, and deaths byage and sex. Stillbirths are tabulated by sex,,region, and age of mother. The causes of deathare presented as numbers and rates by sex andage according to the A-list of the InternationalClassification of Diseases. The number and ratesof perinatal deaths are calculated from stillbirthsplus deaths during the first week of life. Fourmain groups of causes of maternal deaths areindicated: Complications of pregnancy (Inter-national Classification of Diseases numbers630-639), Abortion (640-645), Complications ofdelivery (650-662), and Complications of thepuerperium (670-678). All birth, death, still-birth, and perinatal death rates are shown ‘as””reported and as adjusted for underregistration;the adjustment methods are clearly explained.
In addition, the National Statistical Office isan important user of primary vital statisticsbecause its work is limited to conducting popu-lation censuses; special population surveys, andanalyses.
EVALUATION
Of the 36 countries in the Asian and Pacificregion, only 9 countries (or 25 percent) can beconsidered to maintii.in “reasonably complete”ti~al statistics. Although Thailand is among the27 countries with inadequate vital statistics, itsvital registration system must be regarded asrelatively well developed. Several attempts havebeen made to estimate the completeness ofThailand’s vital statistics by comparing theregistered rates with independent estimates orthrough special surveys conducted by the Na-tional Statistical Office.
Early Surveys
Das Gupta et al.z estimated that in 1960birth registration was “75-76 percent completeand death registration was 57-61 percent com-plete. A more recent study presents estimates ofthe completeness of birth and death registrationin Thailand from the early days of registrationuntil 1970 (table IV-4).3 The estimated numberof births, on which the completeness rate of the
Tabla IV4. Estimated completeness ratas of births and deathregistration by 5-year groups, 1919-69
8irth registration
Registrationpariod
1920-241925-281930-341935-39194044
1845-491950-541955-581660-641865-69
ParCant
53.657.469.275.987.3
60.663.770.3
“82.963.7
Death registration
Registrationperiod
1918-281926-361837461847-581%0-69
Percentcompletion
47.158.374.762.070.1
NOTE: The comuleteneas rates have been calculated fromestimated and registered buths and deaths obtained from amonograph on the population of Thailand to be published bthe Economic and Social CommiAon for Ada and the Pacific.3
birth registration k based, was calculated byapplying the reverse survival method to variouscensuses in Thailand. Deaths were then esti-mated using the balancing equation. The resultsshow a steady increase in the completeness ofbirth registration from a level of 54 percent in1920-24 to 87 percent in 1940-44. This wasfollowed by a sharp drop in the followingdecade, possibly due in part to disruptionsduring World War II and the postwar period.Thereafter, birth registration improved to acompleteness rate of 83-84 percent between1960 and 1969. Death registration followed thesame general pattern of improvement over time(except in the postwar years); underregistrationwas always higher for deaths than for births. Inthe initial period, 1919-29, it was estimated thatfewer than half of all deaths were registered, but
by 1960-70 it was estimated that over 70percent of deaths were registered.
National Statistical Office Surveys
The National Statistical Office has con-ducted two major nationwide studies (Surveysof Population Change) with the dual purpose ofestimating vital rates for Thailand and evaluatingthe completeness of vital registration. The firstof theseA was conducted in 1964-67, in coopera-tion with the Ministry of the Interior and the
Ministry of Public Health. A sample of 302
villages and 17 municipal blocks was chosenfrom the whole country excluding Bangkok-Thonburi. Every household in the sample areawas visited four times a year, and interviewersrecorded all changes in household compositionbetween interviews that were due to births,deaths, or migration. Births and deaths found inthe survey were matched with births and deathsthat were registered in the same sample areas. Inthis way it was possible to see what percent ofevents found in the survey had been reportedand duly registered.
First Suwey of Population Change.–Resultsfor all 3 years of the first Survey of PopulationChange have been published,4 but the first-yearresults (1964-65) are generally considered to bethe most reliable. The first-year findings havebeen widely cited, and it is these results thatwill’ be” discussed. The Survey estimated thatabout 15 percent of births and 30 percent ofdeaths had not been registered in the officialsystem, based on crude birth and death ratesfrom the Survey and the official registration.However, when the actual number of ‘registeredevents was compared with those estimated bythe Survey, the underregistration rates weresomewhat higher—16 percent for births and 37percent for deaths. Among births there was littlevariation in the proportion registered accordingto the age of the mother or the sex of the baby.However, deaths of males were more completelyregistered than deaths of females; and theproportion registered varied substantially by theage of the decedent. Underregistration of deathswas particularly severe for deaths under 1 yearof age as shown in table IV-5.
Second Survey of Population Change.–TheSurvey was repeated in 1974-75 using a sampledrawn from the entire country including
Tabla IV-5. Estimatad completeness rates of death registration,
sex
Male... .. .. .... .. ... .. .. .. . .Female ....................
by sex and age
IITotal Under 1-91 year years
6010-59 yaarsyears and
over
PerCant
69.6 78.8 76.760.0 58.8 69.1 68.6
100
Bangkok-Thonburi. Prelim-maryresults fkom thefirst year of the Survey indicate that registrationis substantially more complete in municipalareas than in nonmunicipal areas.b For munici-pal and nonmunicipal areas together, birth regis-tration was estimated to be 70 percent completeand death registration was estimated to be 59percent complete. These estimates of complete-ness are considerably lower than those made 10years earlier in the first Survey, particularly inthe case of births.
Although the new figures suggest somedeterioration in completeness of vital registra-tion in Thailand between 1964-65 and 1974-75,that conclusion may not be entirely warrantedfor a number of reasons. First of all, the newestimates are preliminary and they represent theresults from only the first year of the Survey.Second, both Surveys are subject to some degreeof sampling error &d, there~ore, small chdgesin the completeness rates may not indicate anyreal change in the adequacy of the vital registra-tion system. Nevertheless, even a cautious inter-pretation of the results would suggest that therewas probably no significant improvement in thecompleteness of vital statistics during the decadefollowing 1964-65.
Supplementary Survey. -In 1966, as a sup-plement to the first Survey of PopulationChange, a special survey was conducted toobtain information about knowledge of, atti-tudes toward, and practice concerning registra-tion of vital events, as weli & reasons whypeople did not register events.G A major goal ofthe survey was to make use of the results toimprove the registration system. The surveyfound that the legal regulations for registeringbirths and deaths were generzdly understood bythe respondents. Over 90 percent correctlyanswered that events must be reported to thekamnan or at the municipality offices. Themajority also knew whose responsibility it is toregister,, events and approximately within whattime period events should be registered. The——majority” also knew that no fee is charged forregistration and that no- documents have to betaken to the registrar. However, there wasconsiderable misunderstanding of the correctprocedure for registering events that occur out-side the tambol of usual residence. Only one-third of respondents knew that such events
should be reported to the registration officewhere the event occurred. Failure to registerevents was evidently due to a lack of motivationon the part of the informant rather than to alack of understanding or because registering theevent was inconvenient. The registrars some-times underestimated the need to record allevents within the specified period of time. Thesupplementary Survey showed that the mainte-nance of vital registration records was oftengiven low priority because registrars were over-burdened with a variety of other tasks.
Individual Items
Although a good deal of attention has beengiven to the completeness of registering vitalevents, somewhat less attention has been paid tothe completeness or accuracy of individual itemson the registration certificates. It should berecognized that the registration certificates arelengthy and that the informant may not knowaIl the detailed information that is requested.Therefore, various items are often Ieft bkmk,particularly on part 3 of the certificate. Inaddition, the recording of cause of death ispaiticularIy problematic because most deaths arenot certified “by a qualified doctor. The 1972figures show that 35.4 percent of deaths arecaused by iII-defined and unknown causes andanother 17.7 percent are caused by senility.Because only 16.2 percent of all deaths in 1972occurred in a hospitaI, it is unlikeIy that theoverall figures can be improved substantially inthe near future.
IMPROVING THE SYSTEM
The Lampang Health Development Project
One major geographically limited project–the Lampang Health Development Project–deserves to be described briefly because one ofits principal objectives is to develop the informa-tion bases for health services development andevaluation:
“The Lampang Project aims to improve thegeneral level of health of the rural popula-tion through the innovative developmentand evaluation of a low-cost integrated
101
health delivery system which will effectivelyreach and serve at least two-thirds of thetarget population within the resources avail-able to the Royal Thai Government.”7
In this Project the following approaches havebeen emphasized:
(a) Integration of all provincial medical/health care infrastructure for improvedefficiency and effectiveness.
(b) Training and development of largecadres of volunteer health workers:health communicators, health postvolunteers, and traditional midwives.
(c) Training and deployment of intermedi-ate level medical health care providers,paraphysicians called “wechakorn.”
(d) Promotion of community involvementthrough village adjunct committees andhealth committees at every administra-tive level, and other features.
The Project is a pilot project because itsexpected outcome is that the key features andinnovations that are”tested and found effectivewill be adopted by the Ministry of Public Healthand the Royal Thai Government for replicationthroughout the Kingdom of Thailand.
The approaches just cited suggest the crea-tion of innovative, information-collecting mech-anisms and the strengthening of the existingones. Particularly in the case of vital statistics(i.e., indicator data based on vital events andpopulation figures), collection of informationhas become an end in itself, rather than asupport to more effective planning and manage-ment of social services, among which are thehealth services. Incidentally, much informationis collected at present, but little analysis oreffective use is made of it especially at theprovincial level.
If there are many unmet needs of the usersof vital statistics and health information, this isdue to shortcomings mainly at the primary localdata collection or registration level. Further-more, ~ was explained earlier in this chapter,the information collected and made available isoften unreliable. This is particularly true of the
number of deaths and even more of the causesof death. If death registration is unsatisfactory,the causes of death, which constitute essentialinformation for health planning and evaluationof the health services, are often not shown, notcertified, and ill defined.
Considering the small amount of analysismade at the provincial level and the lack offeedback in some adequate form to the pro-ducers/users of the information, the provincesare faced with a relative information overload.
Because the Lampang Project is a project ofdevelopment at the rural provincial level, whereoperational management and planning decisionsshould be made, its objective is to concentratemost of the information activities at this pro-vincial level, particularly the analytical func-tions, in support of planning and management.
It is, of course, only legitimate to speak of“information overload” or of “the inadequacyof the data for planning and decisionmaking” ifone has clearly defined the scope of the de-cisions to be taken and the expected results ofsuch decisionmaking; in other words, if theinformation requirements are known in detail.
Increased analytical activity at the provinciallevel does not necessarily mean informationprocessing by electronic computer. Such equip- -ment is generally not available at the provinciallevels; it may also be inappropriate at present.Vital statistics for use in the health informationsystem would have to be analyzed and tabulatedat this level. This will create a number ofadditional statistical activities at the provinciallevel; the understaffed provincial statistical of-fices cannot cope at present with additionalactivities.
Community Self-RelianceAt present, one Project approach focuses on
community self-reliance and an increased socialmotivation of the population. The creation andtraining of three types of community healthvolunteers—health communicators, traditionalmidwives, and health post volunteers–may beexpected to improve the registration of births,stillbirths, and deaths. The health communi-cators are the most important addition to thevital and health information system, becausetheir primary function is to collect and dissemi-nate information in the village. The role of the
102
traditional midwife as a motivator for registra-tion and informant of vital events, however,cannot be rated too highly, especially if weconsider that approximately 60 percent of alldeliveries are attended by these midwives. Thehealth post volunteer who provides first aid andtreatment of simple illnesses, health education,and family planning supplies cooperates with thecommunicators and viIIage midwives and reportsmonthly to the district health officer who inturn sends consolidated reports to the provincialchief medical officer.
Because the officizd registration system ofreporting births, stillbirths, and deaths to theMinistry of the Interior does not meet therequirements of the Project in respect to reliabil-ity of the information registered and reported,the Project’s own “parallel” network of villagevolunteers is gathering vital events data. Thesedata were already compared with the officialregistration data, and some significant differ-ences were noted. These differences could bedue to events, such as births and deaths,occurring in districts other than the usual placeof residence and for which the address was notchanged and the household register card notbrought up to date. That means that for acertain commune, the official registration datamay be lower or higher than the events enteredon the household register card or which werereported by the health communicators.
The village volunteers probably cannot beasked to be responsible for routine reportingbecause they normaIly will be ordy part-timeworkers. This might prove a major shortcoming.Another drawback might be the illiteracy ofmany of the traditional midwives who generallyreport verb~Iy to the Government midwife who,in turn, puts the information into written form.
Every month, the reports on vital eventscollected by the volunteers are sent to thedistrict offices and from there to the provincialoffice. At this level, information is supposed tobe fed back to the various divisions of theprovincial office where it may be used forplanning and evaluation purposes. At the villagelevel there is no such feedback mechanism to thevolunteers. For the volunteer, however, theregular visit of the Government health workermay be sufficient to discuss the work and solveproblems that arise.
Training of alI workers at all levels of thevital and health statistics system is one of thecrucial tasks that has to be planned caxefully andcarried out systematically.
The question of whether the prototypeinformation system can be replicated in anyother Province is difficult to answer at this stage.However, if we assume that in other Provincesthe information needs are similar to the needs inthe Lampang Province, that the same standard-ized information documents are used, and theinformation flows are identical, then the prin-ciples developed for the Lampang informationsystem can easily be applied to other Provinces,with certain adjustments. Taking into accountthe user orientation of modern informationsystems, it is the planners, administrators, anddecisionmakers who will determine for eachProvince the most urgent information require-ments.
Health Planning and Management InformationSystem
The new health planning and managementinformation system started in 1975 is designedto support all planning, management, moni-toring, and evaluation efforts undertaken withinthe framework of the Fourth Five-Year NationalEconomic and Social Development Plan (1977-81). In this report, ondy a concise descriptioncan be provided, outlining the main features of asystem that will at the same time generate anduse vital statistics information. The main ob-jectives of this project that, in its first phase, isbeing introduced in 20 Provinces, are as follows:
To coordinate the collection and processingof aU health and health-related informationin order to make the system as effective andefficient as possible.
To provide information support forplanning, management, monitoring, and eval-uation efforts of National Health” Develop-ment Projects within the framework of theFourth Five-Year Development Plan and tocooperate closely with development projectteams.
To encourage training of various categoriesof health personnel at all levels, includingvillage health volunteers and communicators.
103
To improve the existing statistical informa-tion in terms of quality, reliability, prompt-ness, completeness, timeliness, and specific-ity. The project particularly emphasizes theneed for more complete and reliable vitalregistration data and vital statistics and aimsto improve the registration of births anddeaths. The project also intends to accelerateand improve the reporting system of allhealth institutions in respect to morbidity.
To develop the epidemiological surveillancenetwork and its reporting system from thevillage level to the national level and accel-erate the notification of communicablediseases so that prompt action can be taken.
To suggest revisions in the legislation con-cerning vital statistics according to therecommendations of the proposed AdvisoryCommittee for Vital Statistics. ,
To recommend revision of thd design ofrecording and reporting systems as proposedby the Advisory Committee for Vkl Statis-tics.
GoaZs.-The first goal of the proposedproject is to increase completeness of vitalregistration from 85 percent to 95 percent. forbirths and from 70 percent to 80 percent fordeaths.
Other goals include complete reporting ofcommunicable diseases, especially notifiablediseases, and of resource utilization.
Structural changes.–Some important struc-tural changes are suggested:
Establishment in the Ministry of PublicHealth of a central information center thatwould assume the functions of the HealthStatistics Division and be placed under thedirect responsibility of the Undersecretaryof State for Public Health.
Establishment of an advisory committee forvital statistics.
Coordination of the functions of the CentralInformation Center with the activities of theHealth Planning Division and the Epidemio-logical Surveillance Division.
Training of a--large number of healthpersonnel.
Operational measures.–The innovation inthe proposed system is the decentralization fromthe Ministry of Public Health to the provincialhealth offices of statistical processing and an-alysis of information received by the districthealth office. This conforms to the suggestion tobring the entire planning and management sys-tem “closer” to the population. The advantagesof such decentralization are obvious:
Better contact with the information sourcesand easier verification and rectification ofdata.
A possible gain in specificity, completeness,and quality of information.
The cost of such decentralization and theintensive training efforts might prove a majordrawback.
The provincial information center, previouslythe statistics unit, will collect all informationfrom the district offices, provincial hospitals,district hospitals, medical and health servicecenters, and other health units in the Province,municipality, and the private sector. The decen-tralization of the information processing andanalysis functions to the Provinces follows thedecentralization of planning at the provinciallevel which the information system has tosupport.
Summaries of the processed and analyzedinformation will be sent to the Central Informa-tion Center, and feedback distribution of theprocessed and analyzed information to theprovincial services will be secured.
At the central level, the Central InformationCenter will still be carrying out its functions ofprocessing and analysis. However, in the future,this analysis will be based on informationalready processed, analyzed, and verified by the20 Provinces included in the project. In additionto the provincial information, the Central Infor-mation Center will receive information fromother central health institutions, public healthservices, state enterprises, and the private sector.The Center will verify the information and storeit for annual publication. At this stage, theinformation can then be used for healthplannirig, monitoring,‘health development
and evaluation of theprojects. Furthermore,
104
essential parts of the information can be fedback to the services that have provided the basicdata.
Another feature and responsibility of theCentral Information Center is to cooperateclosely in information exchange with otherinformation producers and users, such as theNational Statistical Office and the NationalEconomic and Social Development Board.
RECOMMENDATIONS
According to the current 5-year plan, dis-cussgd earlier in this chapter, the goals forcompleteness rates for vital statistics by 1981are 95 percent for births and 80 percent fordeaths. If these goals are to be achieved, aconcerted effort toward improvement will haveto be launched by all agencies concerned withvital statistics collection and processing. Severalefforts along these Iines are currently beinginitiated or are planned for the near future.Among these are:
An intensive newspaper, radio, and televisionpublicity campaign by the Ministry of theInterior to explain the importance of regis-tering vital events.
Refresher courses for civil registrars at the,district (amphoe) and commune (tarnbol)levels that emphasize the importance of vitalregistration, demonstrate methods of filling@ certificates, and discuss problems en-countered in registration (such courses wereconducted by the Ministry of the Interior in1973-75 and might be conducted again bythe Ministry of Public Health).
Development of a system by the Ministry ofthe Interior for grading registrars on thebasis of their promptness in turning in formsand the completeness of the forms.
The system of health post volunteers andcommunic-ators discussed earlier.
Various innovative programs on the locallevel such as door-to-door campaigns toregister vital eventsernment services.
and provide other gov-
In addition to these very worthwhile efforts,a number of other activities are suggested forimproving vital statistics in Thailand. As it wasnot possible for the study team to understandfully some of the features of Thailand’s complexvital registration system during its short stay inThailand, no specific recommendations wereformulated. Rather the items that follow areproposed as possible topics for discussion amongpersonnel in Thailand who are concerned withvital registration and vital statistics:
The present considerable delays in the col-lection, processing, and publication of vitalstatistics might be shortened by applying thefollowing procedures:
Strict observation of reporting schedulesat all levels of the system includingcutoff dates in order not to delay pub-lication of the information.
Publication of preliminary data onbirths, deaths, and stillbirths on an an-nual or even a quarterly basis. Finalresults would be published in subsequentreports.
A selection of only the most useful itemsof information. It may not be necessaryor useful to code and key punch allitems from the registration certificatesevery year, particularly items not cur-rently analyzed and published.
By applying scientific sampling methods,less than 50 percent of the birth certifi-cates may be included in the sample.Sampling of death certificates shouldako be explored.
Separate analytical studies based on the vitalstatistics information should be encouraged.
The proposed information system for healthplanning, management, monitoring, and eval-uation should provide a mechanism forestablishing regidar contacts between infor-mation producers and users (such as plannersand administrators) so that the informationavailable will meet the planning and manage-ment requirements.
105
The proposed decentralization of theamdy-sis and processing functions from the na- .tional to the provincial level would havemany advantages, as discussed earlier. How-ever, the successful implementation of thisproposal depends on the thorough trainingof provincial staff and close supervision bythe Ministry of Public Health. For thepurpose of standardization, guidelines fortraining the staff should be prepared.
Continued evaluation of the completenessand accuracy of vital statistics is necessarj.A repetition of the Survey of PopulationChange by the National Statistical Officeafter the 1980 census is recommended. Itwould also be worthwhile for the Ministry of
Public Health to conduct specific evaluationstudies.
The proposed information system for healthplanning, management, monitoring, and eval-uation recommends the introduction of a layreporting system, particularly for use byvillage volunteers. This system is based on aclassification of symptoms and is designed tofacilitate the reporting of causes of deathand to improve the cause-of-death statistics.In order to ensure the successful applicationof the system, village volunteers and localhealth workers would be trained in theappropriate use of the lay classification.Training manuals and guidelines will have tobe developed.
REFERENCES
lDepartment of Economic and Social Affairs:l%inci@es and Recommen&tions for a Vital Statistics.System. Statisticalpapers,SeriesM, No. 19, Rev. 1. NewYork. United Nations, 197%
2Ds+s Gupta, A., Choteehanapibal, S., Chalothorn,T., and Siripak, W.: Population perspective of Thailand.Sankya: Indian J. Stat. Series B. 27 (1 and 2): 1-46,1965.
3Economic ~d so~~l Commiggion for Asia ad thePacific:’ Popukztion of Thaikand ESCAP Country Mono-graph. Series No. 3. Bangkok. United Nations. 1976.
4National Statistical Office: The Survey of Populat-ion Change, 1964.67. Bangkok. Office of the PrimeMinister, 1969.
5National Statistical Office: 2%e Suroey of Po@da-tion Change, 1974-75. Preliminary report. Bangkok.Office of the PrimeMinister,1977.
6Natiqnal Statistical Office: The Survey of Popula-tion Changes. Supplementary Survey on Knowledge of,Attitude Toward, and .?%ctice Concerning Official Reg.istration of Births and Deaths, Mar. 21-Apr. 22, 1966.Bangkok. Office of the ~lme Minister, 1969. I
7~is@ of pubfic Health: Development andEvaluation of an Integrated Health Delivery System inThailand. Lampang Project, Provincial Chief MedicalOfficer, Lampang, Thailand, 1976.
106
APPENDIX
CONTENTS
FormsReproduction of Birth Certificate-Parts 1,2, and 3............................................................................ 108Reproduction of Death Certificate-Parts 1,2, and 3 .......................................................................... 109Reproduction of Stillbirth Ccrtitkate-Parts 1 and 2............................................................................ 110Reproduction of Medical Certificate of Cause of Deati ............................................................. .......... 111
107
of Birth Certificate-Parts
Note: Parts 1 & 2 are identical to this
Office of the registrar -------
APPENDIX
1, 2, and 3
B1RTH CERTI FICATEPart 3No. 1
. . . . . . . .
1. 1.1 First Name Family Name 1.2 sex 1.3 Nationality
MaIc Female
❑ ID
1.4 Date of birth (Day, month, year) Time Month Year
why Lunar calendar
‘“c’c& ‘&
1.5 Place of birth (house No., village No.. lane, scrcct) Comm.nc, district, province Country
2. 2.1 First Name Maiden Name 2.2 Agc 2.3 Nationality
Mother
Years
2.4 Place of rcsidencc House No. village No, Commune, District, Provincemm. as place of lane. street
birth of baby ❑
3< 3.1 First Name Family Name 3.2 Agc 3.3 Nationality
Father Years
4. 4.1 First Name 4.2 Address (House No, village No. Ian., street, commune, district,
province)
Informant 4.3 Relationship 4.4 signature of informant
HouseholdFather Mother Official
Attendant other
head at delivery
•1 ❑ 0 ❑ ❑ ❑5. Date of registration (day. month, year) 6. Date of change of name (day, month, year)
7. Signature of registrar 8. Si8nature of registrar for chan8c of name
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
( ) ( )Registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. 9.1 Place of birch 9.2 Reli$onMother Provinm. countrg
9“3 ‘~::dc •1 ‘“”C%4 Occupation
10. 10.1 Place of birth 10.2 Religion
Father Province. country10’3 ~;;;, ❑ ‘“”C
10,4 Occupation
11. Father’s usual place of residence Ad&ess (House No., village No., lane, street. cormnu”c. district. province)
Same as Baby’s place
Mother’s •1 of birth •1 11.111112. 12.1 Single birth 12.2 Multifdc birth 12.3 Birth order
•1 Twins ❑ Three ❑ Four ❑ OncaTwoD Threen Fo”rn
12.4 Parity 12.5 Duration of Gestation 12.6 Wci8ht 12.7 HeightMonths H Weeks ❑ Grams
[IllCentimeters
12,8 Injury due to delivery 12.9 Abnormal body
❑ Yes ❑ No r No❑ Y,,❑ r13. 13.1 Illness d“. m pregnancy 13.2 Illness “m due toprcg”ancy
❑ Yes ❑ No r No❑ Y..❑ rIllness 13.3 Illness duc to dciivcry 13.4 Spccid delivery
of ❑ Yes ❑ Nor No ❑ Y., ❑
motbcr r
13.5 Marriage registration 13.6 Duration of maniagc 13.7 Total No. of cbildrcn including ncwbor” and anyH Y., ❑ No ❑ Yc.rs who dlcd
r No. living No. dead No. stillbornn-
111114, 14,1 . Traditional
By herself Ncigbbour midwife Midtifc Nuke midwife Junior sanitaria. Medical doctorAttcn- n ❑ •1 ❑ ❑ ❑ •1dant at
r
birth14.2 First Nmnc Last Name 14.3 Address (ho.sc No, til12gc No, hme, street,
comm””c, district, province) I
I II I II15. Si8naturc of attendant at birtb 16. Signature of doctor
I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
( ) ( )
108
Reproduction of Death Certificate-Parts 1,2, and 3
DEATH CERTIFICATE
Note: Parts 1 & 2 arc identical to thisPart 3
] No. I(Wire of ,h. ,,+.,.,. . . . . . ..-. ..... . . .... .........
1. 1.1 First Name Last Name 1.2 Sex 1.3 Age 1.4 Nationality
Male Femafe Years
Decedentnm
1.5 Date of death (day, month, year) 1.6 Cause of death
2. Place 2.1 Address (house No, village No, lane, street, district, province, comury)
of
Death
3. 3.1 Father’s first name Last Name 3.2 Nationality
Parents
of
decedent3.3 Mother’s name 3.4 Nationality
4. 4.1 First Name Last Name 4.2 Relationship
Household Father Mother Husband Wife Health Official Othej
Informant ~ncl EICIEI CID4.3 Address (house No, village No, Ianc, street, commune, district, province)
5. 5.1 Disposal of body 5.2 Place (commune, district, province)
Corpse saved Cremated Buried
❑ ❑ 0
6. Date of rcgktration (day, month, year) 8. Signature of registrar
7. Siinature of informant. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
( ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Registrar . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. 9.1 Father’s place of birth 9.2 Father’s occupation 9.3 Mother’s place of birtb 9.4 Mother’s occupationParents (country, province) (country, province)
10. 10.1 Religion 10.2 Marital Status
Decedent 103 ‘d~Gn de ❑ None
10.4 Ckcupation
single married ieparated divorced widowed
r n n n n ra
11. Decedent’s place of birth, Address {house No, village No, lane, street, commune, district, province)..
12. Usual place of rcsideri~c Address (house No, village No, lane, street, commune, district, province)
of decedent same as place
of death r 11111113. Major symptoms of illness 13.1 Duration of stay at place of death (years, months, &ys)
14. 14.1 Certified by
Traditional Midwife Traditional doctor Midwife
o
Nurse midwife Junior sanatarian Medical doctor
c1 a ❑~
Cause14.2 First Name Last Name 14.3 Address (house No, Village No, lane, street, commune, district, province)
of [Ill I Ideath 14.4 Cause of death
from Duration of illness
certi-
fied Years Months Days Hours
card
(1) Nameofdisease A. Duectantecedent cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
B.lntermediate antccedentcause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. Underlying cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) other important cause
14.5 Autopsy performed
❑ No •1 Ye,
15. Signature of doctor
. . . . . . ------ . . . . . . . . . . . . . . . . . . . . . . . . -
( )
Reproduction of Stillbirth Certificate-Parts 1 and 2
STILLBIRTH CERTIFICATE Part 2
1Note: Parts 1 & 2 are identical
nfc.. ,.C.l.. ..-%... . . . . . . . . . . r I I 1 i 1 I t 1 I. ..... -. .... ..&... -. I I I I I I I I I I
1. 1.1 Date of delivery (day, month, year) Time 1.2 sexMale Femalen
Notfitain0 r
Still-birth
1.3 Place of delivery (house No, village No, lane, street, commune, district, province)
1.4 Important symptoms (of mother and stillborn baby) 1.4 cause of death
llll_
2. 2.1 First Name Maiden Name 2.2 Age 2.3 NationalityYears r
Mother 2.4 Place of retidence same as place of Addrest (house No, village No, lane, street, commune, district, province)delivery ❑
.——cuut3. 3.1 First Name Last Name 3.2 AST 3.3 Nationality
Father Years r4. 4.1 First Name Last Name 4.2 Address (house No, village No, lane, street, commune, district, province)
InfOr- 4.3 Relationship 5. Date of registration (day, month, year)
mant Household Father Mother Official Deliverer Otherhead
•1 ❑ 0 •1 •1 •1
6. 6.1 Disposal of corpse 6.2 Place (commune, district, province)Corpse Saved Buried Cremated
•1 •1
7. Signature of informant 8. Si@uure of registrar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(
. . . . . ..- -------- . . . . . . . . . . . . . . . . . . . . . . . . .
) (Registrar
). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. 9,1 Place of birth (province, country) 9.2 Religion 9.3 EducationD Grade
❑ None 9.4 Occupation
9.5 Wasever checked❑ No , ❑ Yes
9.6 Method of deliveryH Normal ❑ Special
Mother 9.7 Registration of marriage 9.8 Duration of marriage 9.9 Total No. of pregnancies No. living, No. died❑ Yes H No Year month including this one No. died before 28 weeks
r-rI
9.10 Last delivery 9.11 Deliveries 9.12 Date of delivery (date, month, year)SingIe Twins Three Four No. diVC No. stillborn
❑ 000
10. 10.1 Place ofjirth 10.2 Religion 10.3 Education ❑ No;.Father
10.4 Occupation(province, country) ❑ Grade
r r11. Usual place of father’s residence same as 11.1 Address (house No, villagt No., lane, street, commune, district, province)
Mother ❑ Place of stillbirth ❑ I I I I IL12. 12.1 Mukiple hirtb 12.2 Delivery order 12.3 Parity 12.4 Duration of gestation
Twins Three Four
‘“”& 8 ‘5 ‘d ‘H
Months Weeks
❑ 0 rrStiU- 12.5 Weight 12.6 Hcjght 12.7 13me of death ❑ D.ring deliverybirth grins II I I cms U Before delivery ❑ U“knowm r
12.8 Abnormal at birth 12.9 Injured due to delivery❑ No
12.10 Autopsy performed❑ Yes ❑ No ❑ Yes a No ❑ Yes r
13. ~rtified byTraditional midwife Tradition doctor Midwife Nurse midwife
•1
Junior sanitaria Medical doctor
•1 •1 ❑ rCause 13.1 First name
offist name 13.2 Addre& (house No, village No, lane, street, commune, district, province)
death rfrom 13,3 Cause of death Duration of illnesscerti-fied Years Months Days Hourscard
(1) Namoof&sease ~, Dkccta"tecede"t ca"se..., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .B.lntermediate antecedent cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .C. Underlying cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Other important cause
14. Siinature of deliverer 15. Siiature of doctor. . .. ---- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
( )
Reproduction of Medical Certificate of Causeof Death
MEDICAL CERTIFICATE OF CAUSE OF DEATH
DATE OF DEATH
IImmediste cause
State the disease, injury or complication which
caused death, not the mode of dying such as heartfailure, asthemia, etc.
Antecedent causes
Morbid conditions, if any, giving rise to the abovecarqe stating the underlying condition last
IIOther signitkent conditions
Contributing to the death, but not related to thedisease or condition causing it
I I IAGE (In years last birthday)
w“hours ‘
CAUSE OF DEATH
(a) --------------------------------------------------
due to (or as a consequence of)
(b)--------------------------------------------------
due to (or as a consequence of)
(c) -- ------ ------ --------------------- -------- .------
I ---------------------------------------------------------------------------------.-Accident, Suicide, Homicide How did injury occur?
Minutes Iintervalbetween onsetand death
,-------- ----
--------- -.. .
------ -------
------------
---------- ---
Attending Approved
physichn -------------------- ----------- by ------------------------- ----------Signature Siinature
Date ofsignature --------- ----...- Date ofsignature --------- --------
111
ChapterV
Vital Statistics and theVital Statistics Systemin Jamaica
SamKoilpillai,GraceSbaw,andDr.BogsSbiajar
World Health Organization Study Mission to JamaicaJune 6-24, 1977
CONTENTS
Introduction ........................................................................................................................................ ..... 117General Infomation ....................................................................................................................... 117
Organization ............................................................................................................................................. 118Health Sewices............................................................................................................................... 118The Vital Registration System........................................................................................................ 119
Mechanismsof Registration and Certification of Vital EventsBirths
................................................................... 122........................................................................................................................................ .....
stillbirth122
...........................................................................................................$.......................$... 123Deatis .......................................................................................................... .................................. 124Additional Procedures .................................................................................. .................................. 124
Utfization .................................................................................................................................................Public Use of Vital Recor& .................................................................................................................Other Uses...........................................................................................................................................
Health Sewices...............................................................................................................................Research Workers.................................................. .........................................................................Other Uses................................................................................................................................. .....
Use of Vital Statistics ..........................................................................................................................Health Ministry and Local Health Autiotities ................................................................................Nationsl Planning Agency .............................................................................................. ................Department of Statistics.................................................................................................................University of the West In&es..........................................................................................................
126126127127127127127128128129129
Evaluation of Vital Statistics..................................................................................................................... 129Avddih& ..................................................................................................................................... 129Coverageand Completenem............................................................................................................ 129Qu&W ........................................................................................................................................... 130Evahration Mechanism...............................................................................................................!.... 130General Assessment........................................................................................................................ 130
Education and Training Programs .........................................................!...................................................Public .............................................................................................................................................MedicrdDoctors and Other Health Personnel .................................................................................Registrar General’sOffice Staff ......................................................................................................Local Re@trars ..............................................................................................................................Statistician ....................................................................................................................................Information Speciflwti......................................o............................................................................Medical Records Officers,.,,,,.,.!,..,..,,. .............................................................................................
131131131132132132133133
Conclusion............................................................................................................................................ .... 133Availability of Information ............................................................................................................ 134Quality of Information ................................................................................................................... 135Use of Information ......................................................................................................................... 136Coordination and Co~oration ..................................................................................................... 136
Referencca ................................................................................................................................................ 136
Appendix: Forms............................................................!........................................................................ 137
115
LIST OF TABLES
V-1. Population of Jamaica by parkh: 1970”census ............................. ................................................... 118
V-2. Trends in vital statistics: 1970.76 .......... .......................................................................................... 119
116
CHAPTER V
VITAL REGISTRATION AND THE VITAL STATISTICS
SYSTEMS IN JAMAICA
Sam Koilpillai, Grace Shaw, and Dr. Boga Skrinjar
INTRODUCTION
General information
Jamaica, an independent country since1962, is the third largest island in the GreaterAntilles and the largest in the CommonwealthCaribbean. It is 146 miles from east to west and51 miles from north to south, and covers a totalarea of approximately 4,400 square miles. Thetopography and vegetation vary from region toregion, and are dependent on the climaticconditions, which are influenced greatly by themountains. The island consists of a narrownorthern coastal plain, a somewhat broader plainin the south and a limestone plateau in theinterior. The plateau is uneven, broken by manyrivers and streams and numerous upland rangeswith peaks exceeding 4,000 feet (highest peak7,500 feet) in the Blue Mountains, which extendlaterally in the eastern part of the country. Halfof the island is over 1,000 feet above sea level.
The country has a tropical maritime climateand lies in the path of the northeast trade winds.In Kingston (the capital), which is near sea level,the temperature ranges between 70° and 92° F(21° and 33” C). Rainfall is moderately heavy onthe northern coast and reaches 200 inches a yearon the northeastern slopes of ““theBlue Moun-tains. The mountain rain shadow effect, how-ever, reduces precipitation on the southern partof the island. The &nual averageis 74-77 inches.’ The heaviestduring October and November.
for the countryrainfall occurs
For administrative purposes, Jamaica is di-vided into 14 parishes, which are grouped intothree counties (Cornwall, Middlesex, and Sur-rey). (See table V-1. ) Each parish is administeredby a parochial council that has local administra-tive responsibility but limited power and fi-nancing.
Generally reliable telephone and telegraphicservices are available throughout the island, anda postal service is also provided by the Govern-ment. Travel within Jamaica can be undertakenby road, rail, or air. An extensive road networktotalling over 9,000 miles exists. A Govemment-owned railway operates two lines extending 205miles. The internal air service connects Kingston,Montego Bay, Ocho Rios, Port Antonio, andMandeville.
In 1976 the population of Jamaica wasestimated to be 2,072,800. According to the1970 census, 29 percent of the population wasconcentrated in the Kingston-St. Andrew area:41 percent of the population was urban.
Although the population is predominantlyAnglican or Protestant, it also consists of a largegroup of Roman Catholics, a small Jewishcommunity, and a number of other religiousgroups.
English is the official language. A localpatois, which is basically English, is also spoken.
According to Demographic Statistics, 1 29.8births and 7.0 deaths per 1,000 populationoccurred in 1976, with an annual populationincrease of 1.7 percent in 1975 and 1.2 in 1976.
117
Tabla V-1. Population of Jamaica by parish: .1970 census
County and parish
Total ...................
Cornwall County
Hanover ..............................St. Elizabeth .......................St. James ............................Trelawny ......... ...................Westmoreland .....................
Middlesex County
Clarandon ...........................Manchester .........................St. Ann ...............................St. Catherine .......................St. Mary ...... ........................
Surrey County
Kingston .............................Portland ...................... ........St. Andrew .........................St. Thcmsas.........................
SOURCE: Reference 1.
Numbar
1,813,594
58,296125,279100,528
60,504112,663
173,823121,407120,001180,404
98,392
111,87967,497
413,32869,391
Percentof
total
100.0
3.36.95.5
?2
9.66.76.69.95.4
6.23.7
22.93.8
urban
41.4
6.25.2
43.512.714.7
22.521.119.234.il18.2
100.020.588.021.7
Infant death and stillbirth rates in 1!376 were20.4 and 11.0 per .1,000 live births, respectively(table V-2).
ORGANIZATION
HealthServices
Health services are delivered through a net-work of Government and private institutionsdistributed throughout the island.
In Jamaica, the provision of health services ismainly a Government function and is for themost part directed by the Ministry of Health andEnvironmental Control (hereafter referred to asthe “Ministry” or the “Health Ministry”). TheMinistry operates in collaboration with theMinistry of Local Government, which providesenvironmental health services at the parish levelthrough a corps of public health inspectors andother related personnel. The link between thetwo Ministries is the medical officer of heahhwho is an employee of the Health Ministry. He
serves as special adviser on health matters to theParish Councils, which are part of the localgovernment system. The Registrar General’sOffice, which is responsible for vital registrationand vital statistics, is a department of the HealthMinistry.
Medical care is provided through a variety ofinstitutions ranging from hospitals with severalspecialties to the small rural health clinics.
Present hospital services are divided, foradministrative purposes, into nine hospitalregions, each with its own hospital managementboard. Excluded from this system is UniversityHospital, which has its own board, and BellevueHospital, which specializes in mental care. KingGeorge V Memorial Sanatorium, a tuberculosishospital, is regarded as a separate region. Each ofthe other regions contains a group of three orfour hospitals within a given geographic area.
The central responsibility for the administra-tion of preventive health services lies with thePrincipal Medical Officer for HeaIth and thePrincipal Medical Officer for Maternal and ChildHealth, who are both under the directorship ofthe Chief Medical Officer. These services aremanaged at the parish level ,by the medicalofficer of health who is the foremost healthofficer at this level. However, he has no formallinks with the hospital system. This officer isresponsible for all the health services providedthrough the health centers and dispensaries inhis parish. The services provided through themedical officer of health and his staff (publichealth nurses, public health inspectors, mid-wives, community health aides, and others)include all maternal and child health programs,family planning services, and immunization.
The concept of the Cornwall County Pro-gramme, a demonstration project ~or the othertwo counties, is that at the county level, therewould be an almost autonomous administrationwhich would be responsible for the affairs of theprimary health system. In each of the fiveparishes of the county, the medical officer ofhealth would be the head of all health personnel.
The project provides for the development of57 new health centers that would be classifiedinto four types:
A type 1 center is the smallest and approxi-mates the present maternal and child health
118
Table V-2. Trends in vital statistics: 1970-76
1970 ........................................................................1971 ........................................................................1972 ........................................................................1973 ...................................................... ..................1974 ............ ............................................................1975 ........................................................................1976 .................................................... ....................
Births
Number
64,37566,27766,21961,85761,50661,56261,675
Rate 1
34.434.934.331.430.630.128.8
Deaths
INumber Retel
14,352 7.714,078 7.413,970 7.214,157 7.214,374 7.214,004 6.914,635 7.0
Infant deaths
Number
2,0711,7982,0481,6221,6121,4271,256
Rate*
32.227.130.926.226.223.220.4
Stillbitihs
Number
528744675616622659680
Rate*
8.211.210.210.010.110.711.0
lPer 1,000 mean population,‘2Per 1,000 live births,
SOURCE: Reference 1.
clinic or dispensary. It is staffed by one and disseminating information on births, deaths,midwife and- two community health aideswho assist in various education, motivation,and followup activities, such as nutritiondemonstration, food supplements’ distribu-tion, patient referral, and first aid. It oper-ates daily and serves approximately 4,000persons.
A type H center is slightly larger andapproximates the present health center. Itsstaff includes the same type of staff as thatof a type I health center plus a registerednurse, a public health nurse, and a publichealth inspector. A doctor and a pharmacistvisit the type II health center at regularinterwds (about twice a week). It servesapproximately 8,000 persons.
A type 1.1 center is staffed by a full-timephysician and a full-time pharmacist, anassiatant health educator, and a nutritionassistant. This center provides a compre-hensive health service to patients and re-ceives all referrals from the type I and IIcenters. It serves 16,000-20,000persons.
A type W center is located in each parishand is the parish headquarters of the publichealth staff. The staff includes the sametype of staff as that of a type 111center. Itis located in the hospital compound.
The Vital Registration System
The functions of recording, reporting, collec-ting, collating, tabulating, analyzing, publishing,
and stillbirths and those of training personnelinvolved in the vital statistics systems are per-formed by several governmental agencies. Theseinclude:
Ministry of Health and Environmental Control
Registrar General’s Office
Vital records and registrationDistrict registrars’ officesLocal re@strarsVital statistics
Health Services Units
Health Statistics UnitHospital medical records departmentOffices of medical officers of health atparish maternal and child health /family planning clinics
MidwivesRural maternity hospitals
Ministry of Finance
Department of StatisticsNational Planning AgencyCentral Data Processing Unit
University of the West Indies
Department of sociologyDepartment of social and preventivemedicine
Others
College of Arts, Science, and TechnologyPolice (Ministry of National Security)Coroners (Ministry of Justice)
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Regitrar General’s Office.-The main Gov-ernment agency responsible for vital records andstatistics is the Office of the Registrar General,which is organizationally a part of the HealthMinistry. However, the Registrar General’s Of-fice is located a distance of 13-14 miles from theMinistry, and day-to-day contact between thisOffice and the other units of the Ministry arenot easily or satisfactorily accomplished.
The collection, checking, and indexing ofthe registration documents from the local regis-trars are done at the Registrar General’s Office.
Under the present law (The Registration[Births and Deaths] Act, 1881) the Minister ofHealth has the authority to divide the parishesof the island into registration districts. He mayalso alter the districts by changing the bound-aries, by the formation of new districts, or bythe union of existing districts. These changeshave to be officially announced. The boundariesof these districts do not necessarily have tocorrespond to the administrative boundaries ofthe district. At present there are about 380registration districts. Each of these districts has aregistrar who is appointed by the Minister ofHealth or by the Registrar General with theapproval of the Minister of Health. The registrarin turn appoints a deputy registrar with theapproval of the Registrar General. Both musteither live in or have a known office within thedistrict. Many are postmasters; others are privateindividuals who set up offices in their homes.The registrar must be on duty at his home oroffice on the days and hours approved by theRegistrar General for the purpose of registeringbirths and deaths. A signboard with his nameand title, together with the office days andhours, must be placed on the outer door of hishome or office.
While functioning as registrars, the registrarsand deputy registrars receive no fixed salariesand have no status as Government employees.For each registration, they are paid a small fee,which is not considered a salary, by the centralGovernment. These fees, although slightly highernow, have remained about the same for years.The fees paid to postmasters are smaller thanthose paid to other registrars because the post-masters are also Government officials and theycarry on the task of registration during regularoffice hours. A registrar using his dwelling as an
office receives a small rental fee for the use ofhis home. The registrar also collects other smallfees, for example, from the mother when thename of the child has to be changed or added tothe registration form and when she requests acertificate of registration of the birth, and fromthe Government for Supplying the medical of-ficer of health for the parish with lists of birthsand deaths registered during the month. TheRegistrar General has requested that these feespaid to registrars be increased and that they begiven a retainer for their services, but this hasnot yet been approved.
The registration of a vital event must bedone at the registrar’s office nearest to wherethe event occurred. Should there temporarily beno registrar or deputy registrar in a district, theRegistrar General requests the registrar ofanother district to undertake the registration.The Registrar General then places a notice tothis effect on the signboard of the absentregistrar for the information of the public.Without this permission, a registrar cannot regis-ter an event that took place outside of hisregistration district.
The Registrar General provides the registrarswith registration books (sometimes in shortsupply) for registering live births, stillbirths, anddeaths. The registrars are supervised by the stafffrom the Registrar General’s Office whose dutyit is to visit the registrars and clear up anymisunderstanding of the registration process.Each registrar should be visited at least once ayear, but this has not been happening becausethere are only two supervisors for the wholeisland who also perform other routine duties inconnection with the routing of the registrationdocuments within the Registrar General’s Office.
The number of personnel engaged in statis-tical activities at the Registrar General’s Office issmall. The data processing unit has three key-punch machines, two verifiers, and one sorter;the personnel assigned to this unit are engaged inproducing alphabetical indexes for the purposeof records retrieval. There is no programmerconnected with the Registrar General’s Officewho is responsible for producing statisticaltables. Programmers have to be hired from theoutside. The alphabetical indexes probably willbe produced at the Minister of Finance’s CentralData Processing Unit. At the time of this report,
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preparatory work was being dorie for 1969 atthe Registrar General’s Office,
Health Services Units.–The majority ofbirths either occur in the hospitals -or aredelivered by the public health midwives. Thenumber of deaths that occur in hospitals varies.Information is recorded, reported, or processedto a limited degree by: the medical recordsdepartments of hospitals, the rural maternityhospitals, the maternal and child health/familyplanning clinics, the midwives, the parish officeof the medical officer of health, and the HealthStatistics Unit in the Health Ministry to whichthe data and summary reports are sent by thevarious health service units involved. Moreover,the Medical Records Officer at University Hos-pital and the midwife at the rural maternityhospital in the parish of St. Thomas are alsolocal registrars for the vital events that occur intheir institutions.
The Health Statistics Unit has two sections.The first section, which used to be part of thenow defunct family planning board, handles thedata (including those on births and infantdeaths) received from maternal and childhealth/family planning clinics. It has 3 keypunchmachines, 2 verifiers, and 1 sorter, and a staff of15 that includes a statistical officer. The othersection has a staff of six including two statisticalofficers. It handles mainly summary tables (in-cluding data on births, deaths, and stillbirths)received from the various institutions and theoffices of the medical officers of health. Thetwo sections of the Health Statistics Unit are inthe process of being integrated.
With the proposed reorganization of thehealth services in the country to be patternedafter the pilot project in Cornwall County, thehealth statistical services are also in line to bereorganized.
Department of Statistics.-The Departmentof Statistics, part of the Ministry of Finance, isthe central statistical agency for the country.According to the law, it is obliged to supplystatistical data to interested agencies. The De-partment has been engaged in a variety ofactivities related to vital statistical systems. Forexample, the Department has recently initiated acomprehensive analysis of the system of civilregistration in general. In 1975, a study on thecompleteness of registration was conducted;
final results have not yet been obtained. Afertility study is also in progress. Furthermorewhenever population estimates, which areusually computed and published by the Regis-trar General, are not available, the Departmentsupplies these estimates.
The Department, for example, also periodi-cally engages in the analysis and publication ofvital statistics in the annual publication Demo-graphic Statistics.
National Planning Agency.–The NationalPlanning Agency, Ministry of Finance, is in-volved with the Registrar General’s Office andthe Department of Statistics in arriving ataccurate estimates of population based onbirths, deaths, and migration. The Agency alsoanalyzes and publishes some of the vital statis-tics in its annual publication Economic andSocial Survey, Jamaica.
Central Data Processing Unit.–The CentralData Processing Unit, Ministry of Finance, isresponsible for processing data, including dataon births and deaths of infants born to patientsseen at the maternal and child” health/familyplanning clinics, received from the Health Statis-tics Unit. It also compiles alphabetical indexesfor the Registrar General.
University of the West Indies.–The depart-ment of sociology and the department of socialand preventive medicine of the University of theWest Indies have been engaged in activitiesrelating to vital statistics and have conductedstudies in this area. The department of sociologywas responsible for an analysis of fertility in theWest Indies that was based largely on materialfrom the 1960 census. The results of the studyhave been published in Fertility and Mating inFour West Indizn Populations. 2 Several studiesrelating to mortality in Jamaica including theInter-American Investigation of Mortality inChildhood were carried on by the department ofsocial and preventive medicine. In the early1960’s the department also conducted anotherstudy on childhood mortality. The results of thelatter study have been published in a paper“Child Mortality in Jamaica.”3
In addition, the department of sociology wasclosely associated with the 1960 and 1970censuses in the West Indies. During the 1960census a series of tests were carried out by thedepartment to match the census information
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with the records at the Registrar General’sOffice. The department was also involved in thedesign of a system for processing (using mark-sense sheets for the computer) the data on birthsand deaths co~ected at the Registrar General’sOffice.
College of Arts, Science, and Tech-nolqgy.-The training of medical records andhealth statistics personnel at the intermediatelevel, who will be directly or indirectly engagedin vital statistics systems, is primarily the respon-sibilityy of the College of Arts, Science, andTechnolo~
Police and coroners.–The Ministry of Na-tional Security (police depatiment) and theM@istry of Justice (coroners) are also involvedin the vital statistics systems to the extent thatthe data relating to deaths due to unnaturalcauses or of an indeterminate nature originatewith the police and the coroners.
Coordinating mechanism.–The need forcoordinating the involvement of the variousGovernment units in activities concerning vitalstatistics was recognized, and a National Com-mittee on Vital and Health Statistics was inoperation during 1965-69. The Committee con-sisted of representatives from the RegistrarGeneral’s Office, the Ministry of Health, theDepartment of Statistics, the Central PlanningUnit, the Ministry of Finance, the University ofthe West Indies, and the Pan American HealthOrganization/World Health Organization. Nostich coordinating mechanism exists at present.
MECHANISMS OF REGISTRATIONAND CERTIFICATION OF
VITAL EVENTS
The registration of births and deaths inJamaica was made compulsory in 1878, Prior tothis the Anglican Church, which kept records ofbaptisms, marriages, and burials, was authorizedby law to forward quarterly transcripts of theserecords to the then Island Secretary in SpanishTown. These records, some dating back to 1664,have been preserved in the Archives and are stillavailable for reference.
BirthsUnder the present law it is the duty of the
mother and father of the child to give the local
registrar the particulars required for registeringthe birth within 42 days of birth and to sign theregistration form (see appendix, “Forms”) in thepresence of the registrar. If either parent fails todo this, the person in whose house the birthoccurred, any person present at the time of thebirth, or the person in charge of the child isrequired to give the particulars to the registrarand to sign the registration form.
For births occurring in public or privatehospitals or institutions, the person in charge ofthe institution is required to send to theregistrar, withii 14 days of birth, the prescribedcertificate signed by the mother (see appendix,“Forms”). Upon receipt of this notification theregistrar then registers the birth.
This form of notification has three parts:
1.
2.
3.
The counterfoil, which is kept in theinstitution for reference.
The body of the form with the informat-ion necessarj for registration, which issent to the registrar after being com-pleted.
The Certificate of Naming, which is givento the mother in the case-of a living ;hildfor whom no name has been decidedbefore leaving the institution. Themother is instructed to complete thisCertificate and take it to the registrar.This Certificate of Naming cannot beused after the child has been baptized. ACertificate of Name Ghen in Baptism(see appendix, “Forms”) should be ob-tained and given to the registrar whoenters the particulars on the registrationform and counterfoil if they are still withhim. However, if more than 12 monthshave gone by since the registration, thename may not be added to the regis-tration entry or altered without thewritten authority of the Registrar Gen-eral.
When a birth does not take place in ahospital or institution, it is the duty of themidwife in attendance to notify the registrar ofthe birth within 48 hours of its occurrence. Thedifficulty here is that all births occurring outsidehospitals or institutions are not attended by a
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registered midwife. Traditional midwives still dodeliveries, but the number of such deliveries isnot known. In addition, in one district visited itwas stated that the midwives give the notice tothe mother to take to the registrar. This pro-cedure gives rise to the possibility that the eventmay not be registered.
In the case of a foundling, it is the duty ofthe person who found the child or the person inwhose care the child is placed to give theregistrar within 7 days of finding the child anyinformation they may have and to sign theregistration form. For every birth or deathoccurring on board any ship moored in port orany water within the limits of the island, it is theduty of the master or chief officer to report theinformation necessary for registration.
The informant is not charged a fee for theregistration of a birth that is completed in theoffice of the registrar. However, if the registrar isrequested, in writing, to go to a residence toregister the birth, he is entitled to a fee.
Upon completion of the registration of thebirth, a Certificate of Registry of Birth (seeappendix, “Forms”) is given to the parent, ondemand, and on the payment of a small fee. Anotice to have the child vaccinated within 6months of the date of birth also is given to theparent at this time. With the eradication ofsmallpox this is no longer mandatory. Thepractice, however, is still followed. The Certifi-cate of Registry of Birth does not replace thebirth certificate, which is issued, on request, bythe Registrar General only.
In principle it is the duty of the localregistrar to be aware of births occurring withinhis district, Where a birth has not been registeredwithin 42 days of its occurrence, he shouldrequest any of the persons responsible under thelaw to come to his office to give the requiredinformation and to sign the registration form.
The parent or informant has up to 3 monthsafter the birth of the child to supply theinformation necessary for registration to theqrjstrar so that he can register the birth. At theexpiration of 3 months, but not later than 12months after the birth, the information neces-sary for registration must be sworn to and theregistration form and counterfoil must be signedin the presence of the registrar and a justice orsome other responsible witness by the person
supplying the information. After 12 months, thebirth cannot be registered without writtenauthorization by the Registrar General, and anote that this authorization has been given mustbe entered on the registration form and counter-foil.
The name of the father of a single woman’schild may be entered on the registration formand counterfoil by the registrar if (1) bothparties appear before the registrar and sign theform and counterfoil, (2) the registrar is fur-nished with a prescribed declaration of paternityform signed by both parents of the child and bya justice or other appointed officer, or (3) oneof the child’s parents appears before the registrarwith a written request to enter the name of thefather and presents a signed declaration ofpaternity from the other parent. An extra fee ispaid to the registrar when the name of the fatheris registered. The percent of unmarried couplesis high.
With the introduction of the Status ofChildren Act, 1976, which is designed to removethe legal impediments to children born out ofwedlock, many more requests for the father’sname to be entered on the registration form arebeing made.
Stillbirths
The responsibility for registering stillbirthsrests with the person who would have beenrequired to give the registrar information con-cerning the birth if the child had been bornalive. The person giving the information to thenqgistrar should either deliver to the registrar awritten certificate that the child was not bornalive signed by a registered medical practitioneror certified midwife who was in attendance atthe birth or who examined the body of the childor make a declaration using the prescribed formstating that no registered medical practitioner orcertified midwife was present at the birth orexamined the body or that a certificate cannotbe obtained and that the child was not bornalive.
The registration procedure is similar to thatfor a live birth (see appendix, “Forms”). Burialrequires the issue of an order for burial, and theprocedure is the same as that for deaths. Theproblem here is that stillbirths are not usually
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buried in a cemetery. (When a stillbirth occurs ina hospital, the hospital disposes of the body. )
Deaths
When a person dies in any dwelling or isfound dead, it is the duty of a relative, a personpresent at the death, the occupant of the housein which the death took place, or the personundertaking the disposal of the body to give tothe registrar within 5 days following the death,information necessary for registration and tosign the ~egistration form and counterfoil (seeappendix, “Forms”) in the presence of theregisfrar. If a written notification of the deathaccompanied by a Medical Certificate of theCause of Death (see appendix, “Forms”) is sent,to the registrar by the person required to giveinformation concerning the death, the timeperiod for giving this, information may beextended to 14 days.
Upon registering a death or receiving writtennotification (accompanied by a medicid certifi-cate) of the occurrence of a death, the registrargives the relative or person responsible for buriala signed certificate that he has registered orreceived notice of the death. This certificatecomes in three parts: Part A is the counterfoil,which is retained by the registrar; part B is the..—.,.c~rtlficate; &d pait~.C-is ‘a notification of burial.Parts B and C are &ven to the relatives to passon to the cemetery official burying the body.This official retains part B and returns part C tothe registrar within 96 hours of the burial.
In the event of a sudden or a suspiciousdeath, a coroner, justice of the peace, or officerof the constabulary either requests a postmortem examination under the Coroner’s Act oran investigation to determine whether the deathwas the result of natural causes, in which case apost mortem examination is not necessary.
In principle, it is the duty of the localregistrar to be aware of the deaths that haveoccurred in his district. When a death has notbeen registered because the person required togive information did not do so, the registrar,after 5 days and withk 12 months from the dayof ,death, may give written notice to any of theresponsible persons to appear before him tosupply him with this information and to sign theregistration form and counterfoil.
After 12 months, a death cannot be regis-tered without the written authorization of theRegistrar General. A note that this authorizationwas given must be entered on the registrationform and counterfoil.
A Medical Certificate of the Cause of Deathis required for the registration of all deaths.However, when no Medical Certificate can beobtained and no postmortem examination hasbeen made, the person required to inform theregistrar makes a written declaration stating (1)that no medical practitioner attended the de-ceased or (2) where the deceased was so at-tended, giving the reasons why a Medical Certifi-cate cannot be obtained. The registrar thenregisters the death and issues the certificate thathe has received notice of the death. He sends anotice of uncertified death to the medicalofficer of health of the parish in which the deathoccurred. If, as a result of investigation, themedical officer of health sends, within 42 daysof the date of death, a written certificate of thecause of death, the registrar enters the informa-tion on the counterfoil or on the registrationform and counterfoil (if both are still in hispossession) and sends the certificate to theRegistrar Gener+.
Additional Procedures
The birth, death, and stillbirth registrationforms and counterfoils are issued in books thatcontain 100 sheets. These forms are precededand numbered consecutively so as to be able tocheck that all the forms are returned to theRegistrar General at the end of a designatedperiod. The counterfoil serves as a copy of theregistration document and is used for “backup”purposes in the event that the original registra-tion form is misfiled, damaged, or destroyed.Formerly, these forms had to be completedtwice to provide duplicate registration. Since1957, the counterfoil serves as a carbon copy ofthe original registration. This was done toimprove the system and to speed up registration.Unfortunately, the carbon copy sometimes isnot legible or is missing altogether.
To control the entries on the registrationforms and to facilitate filing of these records,the registrar sends the Registrar General, within
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the first 3 days of every calendar month, byregistered mail, all the registration forms forbirths, deaths, and stillbirths completed duringthe previous month. In addition, he sends allsupporting documents, such as certificates ofbirths in institutions, medical certificates, andcertificates of naming. All of these documentshave to be listed on an accompanying sheet. Thedocuments are checked to ensure that all ofthose reported on the list have been received.The registration forms are checked against thesupporting documents to see that all the entriesare correctly written. In theory they should thenbe coded and keypunched before being filed,but in practice only the cause of death is codedand entered in pencil on the registration form.Only items necessary for the Registration Indexare being keypunched. (Prior to 1964 this workwas done by hand. ) After being coded andkeypunched, the forms are filed numerically byyear under a code that refers to the parish andthe district within the parish. Over 12 millioncertificates are now stored in the vault. Al-+ough under the Registration [Births andDeaths] Act, the Registrar General is required tosend to the Minister an annual report on thebirths and deaths registered during the year, thevital statistics processing section has fallen intoarrears. The last printed report refers to 1961.An abridged report giving totals only is,”how-ever, put out annually.
Data for 1962-64 are ready for printing, andthe data for 1965-68 have been checked andkeypunched to some extent. No report, how-ever, has yet been published for any of theseyears. Data for 1969-71, because the year of thecensus is included, have been processed with theassistance of the Agency for International De-velopment (U.S. ), the census research programof the University of the West Indies, and theservices of a private firm. Printing will be doneby the Department of Statistics as soon as errorsthat have been found are corrected.
A great deal of effort on the part of theRegistrar General is being focused on vitalregistration procedures, and the resulting docu-ments are considered to be reliable. Most of thestaff at the Registrar General’s Office are in-volved “in this activity; and very few in th;-preparation of vital statistics. Of a total of 144persons, only 29 are in the vital statistics
section. Of these, three are machine operators.The vital statistics section issues the registrationbooksj checks the entries, and also makeschanges, when necessary.
Increased migration and the resulting de-mand for birth certificates, which began in the1950’s, continue. Schools now require a birthcertificate for admission. In addition, the num-ber of certified copies of registration documentsrequired for litigation purposes is high. As aresult, over 600 applications for certified copiesarereceived at the Registrar General’s Office daily.When the events are relatively recent, the searchprocess slows up because there are no finalprintouts of the indexes although punched cardsfor this purpose are available up to 1968 andthose for 1969 are now being punched. If thework could be updated—as it might be withoutside assistance only—the preliminary indexcould be made available a month after theoccurrences of births or deaths and the finalindex a year later, optimally.
Although written instructions for the guid-ance of local registrars are available, no suchwritten instructions exist for medical recordsclerks in hospitals engaged in notification ofvital events. The procedures practiced were thesame in the hospitals visited. At the UniversityHospital of the West Indies, however, the pro-cedure was not much different from that prac-ticed at the Government hospitals; however, thechief medical records officer is also the localregistrar for births and deaths occurring in thehospital, and another member of the staff of therecords office is the deputy local registrar.Re&tration forms are sent directly to theRegistrar General thus eliminating the delay ofpassing them through a third party.
Each morning, the hospital clerk in charge ofpreparing the notification of births checks thenumber of deliveries that have taken place theday before and that have been entered on thedaily census sheet. In principle, a double checkexists because the delivery book is kept on theward and is filled in by the nurse in charge assoon as possible after delivery.
Medical personnel and medical records clerksare involved in the production of vital statisticsfrom the beginning through the registrationprocess. Medical personnel are also the mainusers of the fiiished product.
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The procedure for notification of stillbirthsoccurring in a hospital is the same as that for livebirths except that special forms are used (seeap~endix, “Forms”). Certification of the causeo}-fetal death is not ‘very reliable.
UTILIZATION
Although it is recognizedregistration system in Jamaica
that the vitaldepends upon
administrative and legal arrangements, the de-mands of users did influence and will hopefullycontinue to influence vital registration and vitalstatistics development in the country. This willdepend on whether the demands on the informa-tion system will be expressed strongly or if theywill be justified. The contents of the systemshould be tailored to the needs of the potentialusers.
The uses of records and vital statistics to bedescribed are not exhaustive. They will be givenseparately for vital records and for vital statis-tics. Responding to the demand for vital recordsoccupies the greater part of the time of the staffof the Registrar General’s Office.
Public Use of Vital Records
The certificate of birth, issued by the Regis-trar General, is a legal document proving iden-tity and civil status.
A number of legal and social rights dependon the identity of the person:
Voting (over 18 years).
Entrance into school.
Issuance of passport.
Eligibility for various allowances.
Insurance benefits.
Property ownership.
Inheritance.
Proof of nationality.
For some of the above purposes, a copy ofthe notification of birth, issued by the hospital,is sufficient. Local registrars cannot issue certifi-
cates of birth; and certificates given to mothersas proof of registration of the baby have no legalvalue.
Any person, upon applying and upon pay-ment, is entitled to obtain the certified copy ofan entry in the register of births containing allinformation that appears on the original entry.
The Registrar General may refuse to issue acertified copy or certificate where there arereasonable grounds to suspect unlawful use ofthe information released. A fee is prescribed foreither the certified cop y of the entry in the birthregister or for a certificate of birth and for thetime needed to carry on the search.
Over 600 persons apply daily to the Regis-trar General, either for a certified copy or tochange certain information on the original cer-tificate.
Retrieval is difficult because exact informa-tion to identify the person in birth register oftenis not provided by the applicant.
Delay of up to a few months can beexpected if the original cannot be found or ifthe birth was not entered in the. register ofbirths.
Registers are kept by parishes and districtswhere the birth occurred, by dates of births. Ifany information is not available, the search istime consuming.
Until 1964, indexes were handled manually.Updating of the index to 1969 has been startedon key-punched cards.
The certificate of death is required”
To issue a burial order.
To provide legal evidence relevant to claims:
For inheritance,
For insurance,
For various allowances,
For pensions.
To prove right of surviving spouse to re-marry.
The application procedure to obtain a cer-tificate of death is the same as that to obtain acertificate of birth. The burial order is issued bythe local registrar or in legal cases by localpolice,
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The certi$cate of cause of death is used insome instances as the only document for regis-tration of death at the local registrar level. Italso is requested for insurance purposes. TheRegistrar General and, in some cases, hospitalsor medical officers of health issue copies of thecertificate of cause of death for this purpose. Inmost cases, this certificate is issued by hospitalsto accompany the notification of death.
Cause-of-death certificates are often receivedvery late at the Registrar General’s Office; andinformation provided on them is not accurate oris even missing:at times.
The cen%ficates of stillbirth have not beenused as vital records by individuals according toavailable evidence.
I Health Sarvicas,
Birth recordsvaccination cards
Other Usas
have been used for issuingto mothers at the time of
registration of the baby. This practice will beomitted because the smallpox vaccination pro-gmm has been altered.
Birth records are also the basis for publichealth programs run at the parish level by themedical officer of health and his staff. However,in many instances birth records are received toolate and therefore cannot be used for opera-tional purposes. In the parish visited, the localregislr& f&wards record; every quarter and notat the end of each month as expected. Hospitalrecords sent to medical officers of health, arealso not received regularly enough to be used forthe daily operation of health services.
Death records with cause-of-death certifi-cates are sent by the local registrar to themedical officer of health for review and forfurther inquiry or action. If sent early enoughand if filled out correctly, their use can bebroadened (e.g., investigation of infectious dis-eases, death of children, maternal deaths).
Research Workers
Birth records have been used for sociologicalstudies omanized by the University of the WestIndies’ de~artment ‘of sociologyment of social and preventive
&d its depart-medicine. The
Department of Statistics has also undertaken afertility study that, however, has not beencompleted.
In addition, a study matching births within a3-year time period prior to the 1960 census withbirths during the 1960 census was conducted bythe department of sociology at the University.
In a matching-type survey undertaken at thebeginning of 1977 by the Department of Statis-tics, Ministry of Finance, birth and deathrecords were traced from the time of occurrenceof the event in the hospital to the time therecords were received at the Registrar General’sOffice. In the case of births, 75 were matchedeasily several months later but 25 were not,most probably because the births had beenregistered under the wrong name.
According to available evidence, researchactivity has declined since late 1960.
Other Use
VIM records received from the local regis-trar by the Registrar General are used as thebasis of payment to the local registrar. Notifica-tions of vital evenlx received by the medicalofficer of health at the parish level are also usedfor this purpose.
Use of Vital Statistics
VM statistics available in Jamaica since1964 as a result of the vital registration systemare limited to totals of registered births anddeaths. Reference was made to the use ofinformation available before 1964. These statis-$iis, however, at present have no operationalvalue. Several examples on how statistics wereused before 1964 were cited. These examplescan be considered only to illustrate users’expectations regarding vital statistics, ratherthan as examples of areas in which statisticswere actually used before 1964.
Four national agencies–Ministry of Healthand Environmental Control, National PlanningAgency, Department of Statistics, and the Uni-versity of the West Indies-are principal users ofvital statistics. They all have manifested interestin vital statistics, they are aware of what datathey need and for what purpose, and they arefamiliar with the existing situation. In addition,
127
they have all attempted to improve the presentsituation and to overcome the lack of informa-tion.
Problems inter ferz”ng with adequate use ofinformation. —Available data do not correspondto the existing needs of the agencies justmentioned because (1) information on vitalevents is presented according to the occurrenceof the event, not according to the residence; (2)data are based on certificates received and assuch do not necessarily refer to the reportingperiod because of numerous late notifications;(3) registration is often incomplete; (4) registra-tion areas do not necessarily correspond to theparish boundaries; (5) detailed vital statisticshave not been available since 1964; (6) discrep-ancies exist between monthly, quarterly, andannual figures; (7) no adequate estimation ofcoverage has been done since the census of1960; and (8) there has been no recent studyregarding the quality of data.
‘Because the ploblems hindering the use ofinformation on a national level are well identi-fied and great interest has been displayed in vitalstatistics, a solution to these problems mightsoon be found if all parties interested in vitalstatistics would coordinate their activities. Fur-ther analysis of these problems, a developmentof a working program, and an assessment of theneeds of all principal users are essential be-ginnings. The roles to be played by each of theconcerned users will also have to be determinedin order to expedite the efforts.
Health Ministry andLocal Health Authorities
The Department of Statistics (recentlymerged with the statistical unit that operatedwithin the framework of the Family PlanningBoard) plays an important role in stimulatingthe use of vital statistics data by assisting otherdepartments of the Ministry. The Maternal andChild Health Department, the Department ofEpidemiology, the Department for Health Ad-ministration, and other agencies base their workon inadequate data available. They have stressedthe need for detailed information, in particular,information on causes of death. Mortality- databy age, sex, and residence are also consideredessential for programming and evaluation pur-
poses, if provided regularly and on time. Thedata on births and deaths available at present areused in a restricted way because data refer to theplace of occurrence of the event and not to theresidence of the newborn or the deceased.
Information on newborn children is of useto health services at subnational (parish, district)levels and at the institutional level. Identifyingthe target population would be of extremeimportance for the management of maternal andchild health services. A development programregarding basic health services for which thisinformation would be of utmost importance hasbeen started. It is not possible to evaluate theprogram on the basis of the parish figuresavailable quarterly and annually because datatabulation is based on the occurrence-of-eventsprinciple.
National Planning Agency
Demographic analysis is a prerequisite forpkmning economic and social development andis an area for which information is neededurgently. Knowledge of population structure,population growth, and geographical distribu-tion is required very often for planning pur-poses.
The use of information is limited at presentto totals of births and deaths provided by theHealth Ministry, data provided by the Immigra-tion Office, medical officers of health ofparishes, and censuses. The analysis of thepopulation according to geographic distributionand internal migration therefore is impossible toconduct based on the data available. Compre-hensive national planning and specific plansrelating to items such as education, welfare, andhealth are areas for which the Agency needsup-to-date and detailed information. At presentthe annual evaluation of specific plans is basedon vital statistics and the findings interpreted inthe Annual Public Statktics volumes. A fewsurveys have been used to fill in the gaps becauseof the lack in the availability of information.
The urgent need for vital statistics was alsomentioned in relation to the preparation of a5-year plan coordinating activities in variousareas in collaboration with the correspondingagencies.
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Department of Statistics
The Department of Statistics uses vital statis-tics primarily for making projections regardingpopulation size and structure for various minis-tries and agencies (e.g., Mini@ries of Agriculture,Education, and Labour). Estimates of thenumber of births and deaths are done bycounting individual records and are used tocompensate for the lack of complete informa-tion. Requests are received for the analysis ofmortality and fertility trends. The NationalPlanning Agency, various institutions, researchworkers, and schools were listed as making themost frequent requests.
University of the West Indies
Vital statistics were used by the Universityto conduct sociological studies of the popula-tion, fertility studies, and studies of healthproblems, and for teaching purposes until 1964.Since then no significant studies have beenundertaken.
EVALUATION OF VITAL STATISTICS
Availability
Since 1964, vital statistical data for theentire country, including those related to age,sex, cause, place of residence (rather than placeof registration), time of occurrence (rather thantime of registration), birth weight, and so forth,which are urgently needed by various users bothwithin and outside the health sector, have notbeen available, although much of the basic dataneeded can be obtained from the originalrecords. The preface to Demographic Statistics1976 by the Department of Statistics expressesthe feeling of one Government agency:
“The statistics of births and deaths have,over the years, become progressively lessavailable in the required form. Thus up-to-date detailed tabulations on births anddeaths are not available, the most recentyear for which these details may be obtainedbeing 1964. Since 1975, the summary tableson number of births and deaths in the mostrecent year have not been provided by the
Registrar General. Accordingly, as was thecase last year, the estimates of births anddeaths and hence of population for 1976have been derived from tabulations of therecords by the staff of the Department ofStatistics.”1
Basic data are recorded either on certificatesof birth, stillbirth, and death, or on otherindividual forms collected by the Health Min-istry or through special studies. Some of themhave been summarized and appear in variousannual reports.
Coverage and Completeness
Every vital event in the entire country isrequired by law to be registered. Registration,however, is incomplete, and the degree ofunderregistration is higher for deaths than forbirths. Among the Government officials inter-viewed, those within the health sector expresseda great concern regarding the completeness ofregistration.
Although no firm estimates of under-registration are available for the island as awhole, the following data may give some indica-tion of this problem:
According to the 1975 annual report of themedical officer of health for the parish ofPortland, there were 440 deaths and 40infant deaths in the parish during 1975 ascompared with 413 deaths and 31 infantdeaths registered.
Incomplete data on stillbirths reported byhospitals for 1975 and 1974 totaled 846 and8444 as compared with 659 and 622 regis-tered in the entire country.s
Skepticism has also been expressed regardingthe relatively low crude death rate (6.9 per1,000 population in 1975) and infant deathrate (6.9 per 1,000 live births) for thecountry and the 1975 infant death rates of10.6 and 11.3 for the parishes of Hanoverand Trelawny, respectively.
Considerable doubt has also been expressedregarding the completeness and validity of dataon infants that die ,within a few hours of birth.
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Because of the bother and possible costs in-volved in burial, these deaths may not beincluded in the number of live births or of infantdeaths. In the rural areas they may not bereported at all if the babies were delivered athome. In the latter instances, even if the child isalive, because the notification of birth is given tothe mother, it may not always reach the localregistrar.
The study by the Inter-American Investiga-tion of Mortality in Childhood deals with thequestion of underregistration and showed that inthe Kingston/St. Andrew area infant deaths wereunderregistered by 10 percent and deaths inchildren 1-4 years of age by 18 percent.6
The proposed reorganization of the structureof the health services as envisaged under theSecond Population Project financed by theWorld Bank should make it possible for a morecomplete coverage of health data including thoserelating to vitzd events. Because the Govern-ment’s program calls for the training of 2,000community health aides, of which 1,200 havealready been trained, and because one of thefunctions of these aides is to periodically visiteach household within a defined geographicarea, it should become possible to obtain moreaccurate and complete information on vitalevents regardless of type of attendant or place ofoccurrence.
Quality
The quality of data is affected at variouspoints along the vital statistics system. At thepoint of origin, the most serious defect is theidentification and/or recording of an eventincorrectly; for example, instead of stillbirths,abortions; instead of infant deaths, stillbirths.This results not -only in incompleteness of dataon infant deaths, but also in inferior quality ofdata on stillbirths and in an overstatement of theincidence of the latter.
Other factors affecting quality came to theattention of the study team.
For example, if a mother comes to the localregistrar to register the birth of her baby severalmonths after birth without the birth notificationthat may have been given to her, the informa-tion recorded by the registrar is based on themother’s recollection of the event, which maynot be accurate.
Similarly, in some instances of death, burialmay take place before registration, and informa-tion given at the time of registration depends onthe informant’s memory.
The certification of cause of death is incom-plete and unsatisfactory; for example, in caseswhere no Medical Certificate of the Cause ofDeath can be obtained and no postmortemexamination under the coroner’s law has beendone. In this case, the parish medical officer ofhealth who may not have known the deceased orthe circumstances of death is requested to“investigate” the case and issue a Certificate ofCause of Death.
Because the facts about the father are notrecorded for many registered births, data onpaternity are probably of doubtful quality andcompleteness.
Misspelling or falsification of names isanother factor that may affect the quality ofdata.
Evaluation Mechanisms
There is no regular or built-in mechanism forthe ewduation of vital statistics. The evaluationat present depends on ad hoc surveys such as theone to be undertaken by the Department ofStatistics and the one taken at the time of the1960 census by the department of sociology ofthe University of the West Indies. In recentyears, however, there has been no evaluation ofthe vital statistics system.
General Assessment
Although data on a number of items arerecorded and checked for accuracy, the proc-essing of the data relating to registered birthsand deaths needs strengthening. Most of thepersonnel at the Registrar General’s Office seemto be engaged primarily in registration, record-ing, filing, and retrieval of the original docu-ments and records. Efforts directed toward theprocessing of the data and the production of acomprehensive set of tabulations and the analy-sis of the data are not effective. The difficultiesirLprocessing the data are apparently related tothe computer system. The system was designedand operates outside the Registrar General’sOffice because there is a lack of personnel fordata processing and statistical analysis.
130
Although the Registrar General’s Office andthe Health Statistics Unit are in the sameMinistry, little or no coordination of efforts todetermine and meet the needs of health servicesand to improve the quality and completeness ofdata exists between the two units.
Even at the level of data recording andreporting, the gaps between the points of originof the information (mostly in the health serv-ices) and the first points of collection (at thedistrict registrar’s offices) are too wide andpermit loss of accurate information.
EDUCATION AND TRAININGPROGRAMS
The mana~ment of a vital registration andvital statistics system requires the collaborationof various groups of people. According to therde the people involved are to assume, threemain groups have been identified: the producerof basic data, the mana@r of the registrationand statistics system, and the user of thissystem. In order to ensure efficient operation ofthe system and to achieve adequate use of theinformation, all three groups will have -to beeducated to the level, that will enable them tofi-dfill their roles. h Jam”aica, the followingpeople are involved in the vital registration andstatistics system and should be considered wheneducation, training, and motivation regardingvital records and vital statistics are discussed:
Public.
Medical doctors and other health personnel.
Registrar General’s Office staff.
Local registrars.
Statisticians (clerks, technicians, profession-als). ‘
Information specialists.
Managers of various programother users of vital recordstistics.
Medical records officers.
Teachers.
activities andand vital sta-
The need for education and motivation of allthese categories has ( been pointed out, andseveral suggestions have been made regarding aneducational program that is to be developed.However, financial problems may impede thedevelopment of a systematic educational ap-proach in this area.
Public
Education of the public has taken variousforms. From time to time there have been radioannouncements informing the people of theirduties regarding registration. However, it is feltthat this should be done more systematicallyand that informative talks should stress the needto register vital events.
The education program for adults includesthe disbursement of pamphlets on registration ofbirths and deaths. Education in this respect,however, should be more intensive. Local regis-trars are not very cooperative because they arenot motivated to cooperate nor are they paid forthis function, only for the process of registra-tion.
Community health aides and midwives,dufig home visits or clinic sessions, could playan important ‘role in educating the public,particularly in instructing mothers on the ad-vantages of prompt and correct registration. Theeducation of a community health aide is not asgreat as that of a health worker but she doesreceive 3 months’ training to prepare her forhome visitation. The importance of vital recordsand registration and of educating the public arenot dealt with specifically during this training.
Medical Doctors andOther Health Personnel
Medical doctors and other health personnelworking within the medical care delivery systemdo not show great interest in providing accurateand prompt data on vital events. Personnelinvolved in statistics are seldom called upon tomotivate them nor is there much encouragementfrom the Health Ministry. Correspondence withtreating physicians in order to correct cause-of-death certificates is made by the RegistrarGeneral’s staff. Unfortunately, the medical pro-fession has not undertaken the task of trainingphysicians in the correct way to complete
131
certificates and in the use of the proper terms todenote causes of death.
Occasionally, medical students are exposedto lectures on population, demography, and vitalstatistics given by the department of sociologyat the University of the West Indies. Similararrangements are also made for medical post-graduate students. Statistics as such are taughtby the department for social and preventivemedicine over a period of 20-30 hours. Cause-of-death statistics have been given a special placein the curriculum. A more extensive educationalprogram is being organized at present at theUniversity.
The study of vital and health statistics isincluded in the postgraduate course leading to adoctorate in public health that has been organ-ized for Jamaican and foreign students by thedepartment of social and preventive medicine atthe University. A similar course has been setupfor other health students.
Registrar General’s Office Staff
Very few people working in the RegistrarGeneral’s Office have been trained in statistics,keeping of medical records, or vital registration,and management.
Training of registration clerks does not exist.In 1968, one member of the staff was trained inthe coding of causes of death. The course, basedon the Eighth Revkion International Classifica-tion of Diseases,7 was organized by the Uni-——.rversity of the West Indies and the World HealthOrganization. The Registrar General’s Office hasnot been informed of any retraining based onthe Ninth Revisions although coding of causesof death is being done at the Office.
Other members of this Office also have notbeen trained. Consequently, an educational pro-gram needs to be developed for the entire staff.The Registrar General, together with peoplefrom the University of the West Indies, shouldconsult with professionals from other countriesto setup training and educational programs.
Local Registrars
The work offor the wholeaddition to the
380 local registrars is the basisvital registration system. Inrecording and reporting that
they are already doing, the registrars could helpto educate and motivate the public regarding theregistration of births and deaths.
Until the present, no educational programshave been developed for local registrars. Thewritten instructions given to every newly ap-pointed local registrar and the occasional visitsby a Registrar General’s Office supervisor ob-viously cannot replace an adequate education.The knowledge, skills, and particularly the atti-tudes of the local registrars will not improve ifthese people are exposed to short trainingprograms. Money problems, lack of personnel torun such short term workshops, time, and thegreat number of people to be trained prevent theinauguration of such an intensive educationalprogram. However, if vital registration and vitalstatistics in Jamaica are to be improved, such aprogram should be considered as a first step inthe development of the system.
Statisticians
Very few personnel have had formal oradvanced training. The University of the WestIndies organizes an annual course of 14 weeksfor nonprofessional statistics officers fromvarious Government departments. Attention isfocused on training in elementary statistics andeconomics, and specific statistical areas, such asdemography and vital statistics, are only brieflypresented to the students.
No training of professional statisticiansexists in the country. People in senior posts arcuniversity graduates in another subject (mathe-matics). Participation in specific problcms-oriented workshops and in internationally organ-ized seminars to study the various aspects ofvital statistics systems would be very valuablefor these people. Progress in the Jamaicaninformation system, including vital registration,depends to a great extent upon this group ofprofessionals and the opportunity for this kindof training should be provided to a few selectedpersons without delay.
Students of sociology in the department ofsociology, the University of the West Indies,take courses in demography and in statistics.However, there are not many posts available fordemographers, and they wind up working inother positions.
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As far as the intermediate level of statisticspersonnel is concerned, the sociology depart-ment at the College of Arts, Science, andTechnology started a combined course for medi-cal records and health statistics technicians in1977. The study of vital statistics is part of thecurriculum. Unfortunately, the Registrar Gen-eral’s Office was not informed irl time to sendany of its staff for this training.
Information Specialists
Education and training of informationspecialists have been neglected. It seems that noeffort has been made to train Jamaican nationalsto take over the work performed until thepresent by outside experts in the areas ofcomputer program design, design of forms, andso forth. Lack of national experts in program-ming was repeatedly pointed out to the authorsof this report and mentioned and identified asan extremely critical one for adequate process-ing of information.
Medical Records Officers
Great effort has been devoted to the up-grading of medical records personnel working inhospitals and other institutions. Several trainingarrangements have been made with the Collegeof Arts and Sciences and Technology in Kings-ton, A national association of medical recordspersonnel also has played an active role in thedevelopment of educational programs for medi-cal records personnel at all levels. A workshop isorganized every year by the national associationin close cooperation with the Health Ministry.Because these workshops are frequented by alarge number of medical records people, theycould be useful in initiating discussions on vitalregistration. “Mini workshops” are organizedsystematically by the Health Ministry to providerefresher courses for hospital staff.
Since 1974, regular medical record courseshave been organized for medical records officers.Formal education at a pre-university level orseveral years of practice are required for admis-sion. The course is of 1 year’s duration. Vitalstatistics and registration of vital events areincluded in the practical training. Not muchtime is devoted to teaching the subject during
the theoretical part of the course. The imple-mentation of what students are taught in schoolis not always possible because of insufficientstaff in the hospitd_s where they practice tocarry through all the procedures such as doublechecking.
For medical records officers in leading posi-tions, a training course of an additional year wasstarted in 1977. Great interest has been shownamong medical records officers in this course.The extent of emphasis on population and vitalstatistics will depend on the teacher becauseeducational objectives have not been clearlystated. A great problem in running the educa-tional program is the lack of Jamaican teachersand tutors. An outside expert can successfullyreplace .a national lecturer on a specific subjecttemporarily. In the long run, however, a teacherhas to be involved closely in the nationaldevelopment of a medical records program. Lackof facilities to train teachers has been empha-sized as a great need that must be met. Equip-ment and visua3 aids to be used in teachingrecording of vital events and statistics would alsobe valuable.
A correspondence course for medicaI recordspersonnel who do not have the opportunity toparticipate in formal training is under discussion.
CONCLUSION
Although the vital registration and statisticssystem in Jamaica has been in existence for along time and has developed, over the years, intoone that could serve the purposes of varioususers, it has deteriorated since the early 1960’s.
Problems identified during the present studyrelate to:
Institutional and organizational aspects ofthe vital registration and statistics system.
Recording, registration, and statistical formsand procedures.
Availability of information.
Use of vital statistics.
Education and training.
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AU the aspects of the problems just indi-cated should be analyzed in greater detail thanwas possible during the study mission beforedetailed recommendations can be offered fortheir solution. The problems are basic and willnot be solved until arrangements are made toeliminate the factors contributing to their ex-istence. Any other alternative suggestion notdirected toward the elimination of the factorsthat provoked the existing situation will nothave any permanent effect on the availability,quality, and use of information.
Availability of Information
The most striking problem–a consequenceof various other problems in Jamaica-is thenonexistence of vital statistics since 1964. Theproblem is of such magnitude and so obviousthat attempts have been made by various agen-cies to assistin the processing of information forthe missing years or to obtain the informationby other means.
At first, the study team was inclined torecommend as a priority that the necessaryresources be sought–personnel, equipment,money, up-to-date information processing. How-ever, as long as the status quo of 1964 istolerated, and the circumstances that hamperthe regular processing and provision of data. inJamaica remain unchanged, the problems willcontinue to exist. Assistance to get data pro-cessed for a number of years, particularly whenperformed by outsiders, cannot be considered asolution to the existing problem, but only atemporary remedy.
Therefore, it is strongly advised that a moredetailed analysis be made of the factors that, atpresent, obstruct the re~lar processing of dataand as a priority assist in their elimination. Theprocessing of data for the past several yearsshould take second place.
After discussing the existing situation with anumber of Jamaican nationals, the study teamidentified several factors that led to the presentsituation. However, after a visit of only a coupleof weeks, it is difficult to judge the importanceof each factor and to make certain that the list isexhaustive and complete.
On the basis of the information collectedduring the visit it is not possible to go into a
detailed analysis of the existing organization ofthe Registrar General’s Office and to offerdetailed suggestions as to what should be done.However, it seems that it is first necessary to:
Establish the need (at all levels) in bothmanpower and equipment for bringing thevital statistics data up to date and keeping itcurrent.
Design a working program for the systematicprocessing of data, including printing, analy-sis, and flow to various decision areas.
Draft an educational program for personnelinvolved in vital registration and statistics.
A small team of nationals, chaired by theRegistrar General, can be charged with the workmentioned. In the implementation of the pro-gram, some outside aid may be needed in theform of equipment, audiovisual aids, organiza-tion of training, financial support for printing,up-to-date processing of information for missingyears, and initiating ad hoc surveys.
In order to begin the work and conduct itadequately, the following suggestions are of-fered:
The Registrar General and one or two moresenior officers involved in vital statisticsshould be given the opportunity of attendinga workshop or training seminar to meetofficials from other countries involved invital registration and statistics to discusstheir probIems and possible solutions. TheChief Health Statistician, the Chief MedicalRecords Officer, and possibly one of theChief Medical Officers from the Ministry ofHealth, may also be invited.
A professional health statistician or demog-rapher should be appointed as DeputyRegistrar General and placed in charge of thevital statistics section.
A programmer who would be responsible forthe programming requirements of both thevital and health statistics sections of theHealth Ministry should be assigned exclu-sively to that Ministry.
134
Duties should be reorganized so as to ensurethe optimum use of existing equipment andpersonnel. An adequate number of machinesand machine operators, as well as assuredcomputer time and printing services, shouldbe provided.
More adequately trained statistical personnelshould be charged with vital statistics work.
It might also be advisable, as an alternativesolution, to integrate all three statistical units inthe Health Mi~istry-the one at the RegistrarGeneral’s Office, the Family Planning StatisticalUnit, and the Health Statistics Unit. A profes-sional statistician should be placed in charge ofall these three units to coordinate, integrate, andsupervise their activities and to meet the needsof various services, including the needs foranalysis of the data. This statistician togetherwith the programmer and the Registrar General’sstaff could provide strong leadership in thedevelopment of vital registration and statisticssystems in the country.
Until the present time, vital registration andstatistics have been combined under one Govern-ment department. This is, without doubt, alogical and economical arrangement. However,the production of vital statistics at the RegistrarGeneral’s Office at present appears to havereceived less attention than the needs for ac-curate and readily retrievable records in order tomeet legal requirements related to registration.It also seems that in the present setting vitalstatistics does not receive the same attention andsupport as other statistical areas which are theresponsibility of the Central Statistical Depart-ment in the Ministry of Finance.
Quality of Information
No studies have been conducted recently toassess the completeness of registration and thequality of data. However, it has been stressedrepeatedly that the situation concerning theseareas still needs to be improved. Various sugges-tions in this respect have been made.
An evaluation mechanism, covering all levelsof the registration process, should be developed,and ad hoc studies similar to the ones performedin the early 1960’s should be repeated on a
regular basis. The design for such an evaluationprocedure might be discussed during the work-shop mentioned previously.
At the same time, other activities that wouldimprove the system should be vigorously pur-sued. These might include:
Wide publicity and training of the popula-tion at all levels regarding:
The need to have vital events registered.
The procedure to be followed to havethese events registered.
The information to be given to theRegistrar General by individuals re-quiring certified copies of these registra-tion documents.
Training of doctors, nurses, midwives,records officen, and local registrars in theirspecific responsibilities in the registrationprocess and the value and use of the result-ing statistics. This training should be givenwhile they are preparing for their professionsand again when they are actually working.
Because a large proportion of vital eventsoccur in hospitals or are attended by healthpersonnel, it would seem advisable that thehospitals and the health centers (to which thehealth personnel are attached) take over thesupervision of the local registration centers andbe responsible not only for the events (births,deaths, and stillbirths) occurring in the institu-tions but for all events occurring in the geo-graphic area served by the institution. Thiswould obviate the necessity of an intermediatestep (notification) between occurrence and regis-tration of most of the events and would ensure agreater degree of completeness of registrationand better quality of data. This suggestedsystem, limited to events occurring in theinstitution, is being followed at the UniversityHospital.
Moreover, the health centers would be ableto collect more complete vital data and couldserve as local registration and reporting unitsafter the proposed plan of setting up an island-wide network of community health aides at-tached to the Government health centers would
135
be implemented. The aides are expected toperiodically visit every household in their as-signed areas and to obtain demographic andhealth information.
A need for uniformity in recording andreporting vital events exists. One reason for thislack of uniformity is the absence of supervisionover local registrars. The supervisory personnelat the Registrar General’s Office should beincreased to provide adequate and frequentguidance to all (including institutions} involvedin recording, reporting, and registering vitalevents. Another possible means of promotinguniformity and improvement in vital registrationis periodic meetings of the local registrars. Theresponsibilityy for registration and notification isnot understood by all because the obligationshave not been expressed clearly.
Feedback to the local registrars through anappropriate mechanism, such as the distributionof a quarterly publication or a newsletter, couldalso serve to educate and motivate them.
U36of Information
At present, it is difficult to talk of the use ornonuse of vital statistics data and to identify theusers. When information becomes availableagain, there will be time enough to consider theadequate transfer of data to those who areinterested at the present time. However, it
would be advisable to consult with potentialusers and to define their needs in terms offrequency, quality, and quantity of data. Theseneeds should influence the processing program.
The education of the user in the proper useof vital statistics has also been set forth as aneed. Educational objectives should be de-termined, and learning materials (audiovisualaids, learning packages, reading material, illustra-tions on use of data, etc.) should be deveIopedto answer the requests of concerned persons.These needs, however, may have to be met withoutside assistance. At the same time, the trainingof teachers should be given a high priority.
Coordination and Collaboration
No overall coordinating mechanism for all“the Government and non-Government agenciesinvolved or interested in an effective and effi-cient vital statistics system e,xistsin the country.The reestablishment of the National Committeeon Health and Vital Statistics, which existed inthe 1960’s, might be the answer to the urgentneed for the coordination of activities in thisarea and for obtaining the collaboration of allthose who are seriously interested in improvingvital statistics in Jamaica.
A mechanism should also be developed thatwill ensure effective liaison and dialogue amongworkers at the local, parish, and central levels.
REFERENCES
1Dep~~ent of Statistics: Demogra~hic Stati”stks>
1976. Kingston, Jamaica. Department of Statistics,Ministry of Finance, April 1977.
$?Roberts, G. W.: Fertility and Mating in Four WestIndtin Populations. Kingston, Jaxmdca. University of theWest Indies, Institute of Social and Economic Research,1975.
3McKenzie, H. I., Lovell, H. G., Standard, K. L.,and Miall, W. E.: Child mortality in Jamaica. MilbarzkMere. Fund Quar. 45 (3, pt. 1): July 1967.
4Health Statistics Unit: Hospital Statistical Tables,Annual 1975. Kingston, Jamaica. Ministry of Health andEnvironmental Control, 1977.
5Registrar General’s Office: Demographic Statistics
of Jamaica, 1975. Kingston, Jamaica. Registrar General’s0~ice,_1977.
6Puffer, R. R., and Serrano, C. V.: Patterns ofMortality in Childhood. Report of the Inter-AmericanInvestigation of Mortality in Childhood. Washington.Pan American Health Organization, 1975.
7National Center for Health Statistics: Eighth Re-vision International Ckzssification of Diseases, Adaptedfor Use in the United States. PHS Pub. No. 1693. PublicHealth Service. Washington. U.S. Government PrintingOffice, 1967.
8National Center for Health Statistics: Ninth Re-vision International Classification of Diseases. Vol. 1.Geneva. World Health Organization, 1977.
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APPENDIX
CONTENTS
FormsReproduction of BKth Registration Form ...........................................................................................Notification of a Birth in a Public Institution or Private Hospital ........................................................Certificate of Name Given in Baptism..................................................................................................Certificate of Naming .......................................................................................................... .. ..............Certificate of Regislay of Birth ............................................................................................................Reproduction of Still-birth Registration Form ............................................................................... .....Certificate of Stillbirth .......................................... ..............................................................................Reproduction of Death Registration Fom ..................... ........................ .............................................Reproduction of Medical Certificate of the Cause of Death ................. ................................................
138139140141141142143144145
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APPENDIX
Reproduction of Birth Registration Form
ORIGINAL FORM A (Section 12)
BIRTH REGISTRATION FORM
“1.BIRTH IN THE DISTRICTOF
2. PARISH 3. NO.
Do not write
in this margin4. Place of Biih
USUAL RESIDENCE OF MOTHER..............................................
5. Date .of Birth ...................... ............ ............. 13. (a) Residence
}
............ ....................
. ................................................................... (b) Town or Village .................... .......... ..
6. Sex .................. .............. .. ............................ (C) parish ............ .............................. .........
7. Name of Child ..................... ........ .......................................... .......................................... 14. No. of Children (a) Alive .........................
8. Physician or registered
}
............................ previously born)
midwife in attendance .................. .......... to mother (b) Still-born ..................
FATHER MOTHER
9. Name and Surname ............................... .... . 15. Name and Maiden Surname ...................... ..
............................. ............ ........................... ..... ......................... ......................................
10. Age at time of birth ........................... years 16, Age at time of birth .......... .. .... .. ........ years
11. Occupation ............................. .................... 17. Occupation .... .................................... .........
12. Birthplace ................................................... 18. Birthplace ...... ............................. .... ............
INFORMANT
19. Name and Surname ............ ..... .................... 21. (a) Residence .............................................
. .............. ............ ......................................... (b) Town or Village.,
.... .. .............................,
ZO. Qudlfication, ... .... ....................................... (C) parish ... ................................................
......................................................................................... .... .. .... .................. .... ............... ...........Signature of Informant
REGISTRAR’S CERTIFICATE
22. (a) Signed in my presence by said informant;
(or)
(b) Entered by me from the particulars on a Certificate received from ....................................................................................................................................... ................................. ................
23. Witness .......................................................24. Date ................ ........ ...................................
25. (Signed) .............. .................. .... ............... ..Registrar
(7) NAME lF ADDED AFTER REGISTRATION OF BIRTH
26. Name ......................................................... 28. Date added .... ........................ ........ .. ........ ...
27. Authority ....................................... ...... ........................................................ ..............................
138
Ncrrtt :—Fsum of certifkate to be SEUT to REGISTRAR by Chief Resident 017icer of public institutionsor person in charge of private hospital. (Section 13(1) )
FORM D
Tsta REGISTIWION (BIRTHSANDDEWHS) Acr
NOTIFICATION OF A BIRTH IN A PUBLIC INSTITUTION OR PRIVATE HOSPITALTo be delivered to Registrar, Births assd Deaths within 14 days of birth::
To the Registrar of Bhths and Deaths for the Dktict of... .. ... . . . .. . . . .. . .. . . . .. . . . .. . . . .... . . . . . . . ... . . . .... . . . .. . . . ....
in the parish of.. . .. . ... . . . . .. . .. . . . . . . .. . . . .. . .. . .. .. . . . . . . .... .. ...... ... . . . . .. . . . .. .
1 certify that tie .... . . . . . . .. . . . . . . . . . .. .. . . .. ... . . . . . . . ..... . ... ..... . . . .child for whom particulars required to be
registered arc given below was born in the.. ... . . . . . . . . .... . .... . ... . . . . . . . . . ... . . . .. . . . .. . .. . . ... . . . .. . . . ... . .. .... . . .. . . . ..at
..................................................................... ........................on the date stated.
Dzte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PARTICULARS F{
(s@d) ...... ................. ....... ... ....... ....... ........... . ....(Chief Resident O@cer or Person i/c
Private Hospital)
REGISTRATION
Date of Birth of Clild ... . . .. . . . .. .. .. . . . . .. .. . . . ... . . . . . . . . .
Name... . . . . . . . . . . .. ... . . . ... . . . . . . . . . . .. . . . . . . . .. .. . .. .... . . . . . ..
&x .... . . . . . . . . . . ... . . .. . . . . .. . .. . . . . .. . .. . . . . .. . .. . .. . .... . . . . . . . .
Physi~ian or Rcgd.Mldvnfe in attendance .... . . . . . .. . . . . . . . . . . .. . . .. . ... . . . . . . . ..
FATSiSR
FullNwc ... . .. . . . .. .. ... .. . .. .... . . . . . . . . .. . . .. . . .. . . .. . .. .. . . . . . . . ..
Age last hrthday ... . . . .. .. . . . . . . .. . . . . . . . . . .. .. . . .. .. . . . . . . . ..
.. . .. ... . . . . . . . . . . ... .. ... . . . .. . . . . . . .. . . . . . . . . . . ... .. . . .. .. ..yws
Usual Rmidcncc .. ... . .. .. . . . . . . . .. . .. . . . .. . ... . . . ... .. . . . . . . . .
Towa or Vdlage ... . .. . ... .. . . . . . . .. . . . . . . . . .. .. . ... ... . . .. . . ..
&cu~tion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bhfrplaca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
N.B. :—In the case oj the child oj a single woman. iof the father on the register of birth in occa
Usual Residence of Mother
rown or Wllage . ... . .. . . .. . . .... . . ... . . .. . .. .. ... . ... .. . . . ....
Parish.. . . . .... . . . . .. . . . . .. .. . . .. . . ... . . . .. . . . .... . . ... .. .. . . . . . ....
N~j&fr3sildren previously born to{
Alive.. . . . .. ..stillborn. . ....
MOTHER
FullNme ... . . .. . . . .. . .. . . .. . . . . . .. . . ... . . . . .. . . .. .. .. ... . . . .. . .. . ....
MaidanSmme . ... . . .. .. . . . ... . . . .. . .. . .. . .. . . .. . . . ... . ... . .. . .. . . . ... .
Age last Mfi&y . .. . . . .. . . . . . ... . . . . .. . . ... . . ... . .. .. . . . . . ....
... ... .. .. . . . . .. . . . . .. . . . . . . .. .. . . . . .. . .. . .. . . . ... .. . .... . . . ..yas
kuption ......................................................
BirthDlacc.......................................................
I proposed to take immediate steph to enter the namence with Sectian 17 of the Act?* . . . . . . . . . . . .. . . . . . . . . . . .. . .
............................................................................Vignn:ttre of parent a other person furnishing particulars
●.. Yes.” or ““No.”
(TO bcgivasslxdyiac aseofativiwdild *
whom DOssarna has baan decided npn).
Nones m m P~
Atanytime rntltin sixwccka ofthc-birUL youmay have a name for the child registcrcrL free ofcharge by delivering the form on the back heraofto the Registrar of Births and Deaths.
............................................................District
.....................................................................
After six wcaks from the date of bwtb tha namewill no longer be ragistcred frea. A fee of tcsr cantswill then lx payable to the Registrar of Births and
Deaths .. . .. .. . . .. . . . ... .. . .. ... . . .. . . . .. .. . .....Diskict
l%o form on the back lisrcof cumot be used aftarthe chfld has been baptized. To register a namegiven in baptism. you must obtain a certi6catc fromthe minister who performs the baptism and deliverit to the Registrar. A fee of ten cents wilf be pay-●ble.
0
Nm4?orrn of “certificate k be given by minister or person performing rite of bapf%n. (Section 2S(2) ).
Mx I
THE ilEGISTRAl!fON (BIRTHS AND DEATHS) LAW
CERTIFICATE OF NAME GIVEN IN BAPTISMThis form is to be completed only by the mi]fister or person who performs the rite Of bapfi~. In c=e of *e da$h, absrmceor rmnovaf of thatminiskr, the minkterar pmwm in c&-
of the ohuroh, chapel or place of worship should use FcmmJ.
.4 fee not exceeding one shiiling is payable to the minister for the issue of this certitk?ak.
A further’ fee (see over) is payable to the Registrar of Births and Deaths when thk certificate is delivered to him.
1, . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..of. . . . . . . . . . . . . . . . . .. .. . . .. . . . . .. . . . . . . . . . . . .. . . . . . . . ...................k tie F’srih of..................,............................~ HRREBY CERTIFY,(fufl name)
thton the...... .... .... ..... .. ...... ......day of ..... ... ........... ... ................ .. ... ... .....19.......... I hqtized by the Name(s) & .................... .. .... ............ ....................... ...............s .... ... .... .. ............. .(nt@k .f.alafe)
dild produced tome by. ..................... .... .. .... ......... .. .... ..........M the. ...... ................... ..of... .... . ..................... . .. .. ....... .............. .................... .... .. ............... .... ..d dackmd by the nid(80W or daughter) (XIwlw 0/ pm) (name of Wmkr)
tohsve been horn at.............. .. ......... ............ ................... .... .... ............ ........ in b P@sh d,....... ..... .. .. ........... .. ................... .. . .. ............... . .................. .. .... .......CQ &l... . .... .......... ...
d~y of.... ........... ... ............ ..................19 .... ...
Witness my hand tti16................... .. ..... .. ...........day ti ............. .. .... ........... .......... ... ... ...19. .......... .. .. ...... ..... ... .................. ... ..............O*ting mini,kr
FOR USE ONLY BY THE BFX31SYBAB OF BIRTHS AND DEATHS
I 11
Iq csza where tie Regisbmr still has in his pmses&m the book .xmbining the wunfafoif dthe bti MgiStmtbn form.
In-where the bmkconkiuing thacounkcfoil of the birth qistmticmfmaisinfbpncloka C4the Regidrar &nezaL
D18tcict Entry Month ofktkm ............ ....... .............IJO.
Dmtriot Month of..... ... ..... ....registmtion of birth....................................... letter8................................mgistrati00 Of tiA ..........................................................
Baptkmal name entered in ●form and counterfoil ●counterfoil only Fee .. .................. .. .... .. Fro.................. . .. ...................... .
Data ..... ... ........ .... ..... ...... .......... . ................. ... .. ... ........... ....... ... .. .... ..&pnatur6 of Ragutrar
I
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
%bb W&h@E dcu -t SPply.
.......................................................Stgnatnrc of Rqdnr
z:at
Certificate of Naming
(To be filled up by the Rcgistror only)
Districtbtters ................o.o..........................
Regn. No .. .. . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .
Dale entered..,..... ............................
Fee .. . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . .. . . . . .
(No jee if entered within 42days oj birth)
Name of Mother .. .. . . . . . . . . . . .. . . . . . . . . . . . . . . . .
.......................................................
CERTIFICATE OF NAMING
(Not to bc used after the child has been baptized)
1.. . . . . . . . . . .. . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . .. . . . . .. . . . . .. .. . . . . . .hereby certify that the(nome irr jull)
. . . . . .. . . . . . . . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . .. . .. ..child born at .. . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(male or jernale) (name of institution or hospital)
in the parish of .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..on the .. . . . . . . . . . . . . . . ..day of .. .. . . . . . . . .. . . . . . . ..(month)
19. .. . . . . . . . has without being baptized received the name(s) of .. .. . .. . . . . . . . . . .. . . . . . .. . . . . . . . . . . .. . .
..............................................................................
............................................................................Signature of Parent or Guardian
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . ... ... .. .To the Registrar of Births and Deaths,
.................................. . . . . .. District
............................................ P.o.
Certificate of Registry of Birth
Birth Entry No . . .. . . . . .. . . . . .. . . . . . . .. . . . . . .. . . . .. . .. . . .
REGISTRATION (BIRTHS AND DEATHS) ACT
CERTIFICATE OF REGISTRY OF BIRTH
I the undersigned, do hereby Certify that the Birth of. ............... ............................ ....
.. ..............................................male child of... ....... ............ ... ......... . ......... ...... ......
born on the............ ......day of.......... ... .... ...................19... .... has been duly Registered
by me.
Witness my hand, this............ ...... ......day of.................... ................ ...19......
~ Registrar of. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J Births and Deaths
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . District
Parish oj . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
141
Reproduction
ORIGINAL
Do not writein this margin
of Still-birth Registration Form
FORM C
STILL-BIRTH REGISTRATION FORM
1. STILL-BIRTH IN THE DISTRICT OF
. Isar, actnm * mln
(Section 32)
L, r~nm-i a. Iwu.
USUAL RESIDENCE OF MOTHER
4. place of Still-birth .... ................................... 12. Residence ....................................................
.................... ................................................ Town or Village ..........................................
5. Date of Still-birth .......... .............................. parish ........ .. .... ............ ................................
................... .................................. ...............6. Sex ..................................... ......................... CAUSE OF STILL-BIRTH
13a. (a) Foetxd cause ..................................... .,.
7. Certificate or
I
13b. (b) Maternal cause ............ .........................
Decktion upon .... ................................ 14. Did child die before
I
..............................
which registered or during Iabour? ............................ ..
FATHER MOTHER
15. Name and Surname
1
...................0,..........
8. Name and Surname Maiden Surname.,0.,.......0........,,....,,,,...............................
. ....... .. ..........................................................9. Age at time of Still-birth .... .... ............ years 16. Age at time of Still-birth ... ................. years
.0. Occupation ................... ...................e.......... 17. Occupation ............ .. ...................................
.1, Birthplace ............. ...................................... 18. Birthplace ............................. .................. ....
INFORMANT
.9. Name and Surname .................................... . 21. Residence ....................................................
. ................................ ................... ................ Town or Village ... ................ .................,, ,,. ,
!0. Qualification ................... ................. ........... parish .......................................................0..
Signed ................. ............. .... ............................... .. ................................................ .....................Informant
REGISTRAR’S CERTIFICATE
~20 S&ed ~ my presence by the stid informant
(or)
Entered by me from the particulars on a certificate received from ...................................,.,.,.,,,.
. ............................................ .... .......... ................ ................ .............................. ..........................
~3, Witness ..................... ............................. ......24. Date .... .............................................. .......... 25. Signed .... .... .......... ...... ........ .... .......... ...........
Regzstrar
I
142
Certificate of Stillbirth
FORM W
REGISTRATION (BIRTHS AND DEATHS) LAW, CHAPTER 337
CERTIFICATE OF STILLBIRTH
‘ This form may bo used only by u Registered Medical Practitioner or o Certified Midwife
FOR USE BY TIIEREGISTRAR
District Letters . . . . . . . .
Entry No . . . . . . . . . . . . . . .
lHEREBY OERTIFY that....................................... . ..................................(Name of Mother)
vwwcldivored of a . . . . . . . . . . . . . . . . . . . . . . . . ..chikl on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...19....(Sex)
at. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . that I
*was in attendcmco at the buth andthdthcddd Wru3NOT BORN ALIVE.*exnmined the body of the clild
Arm I IIEREBYCERTIFY thatto the bestofmy knowkdgc nnd beliefthe childdied.........................(before or durhi . .
Id lonr, n.nd the cmwc of dcnth wns as hereunder written:- -,.
cAusn OF (a) Foetalcrmse . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . .
13EATII (b) Maternal cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Witness my bond this . . . . . . . . . . . . . . . . . . . . ..(lay Of... . . . . . . . . . . . . . . . . . . . . . . ...19....
Signntmw. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Registered qualificrttion
Rcgistere$’No. as a Certified Midwife. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* Delete wldchever does not apply.
NOTICn-..This Certitlccdo mnst be delivered to the Registmr of Births rmd Deaths by the person attending togive information concerning the Stillbirth.
It is NOTau authority for burial.
143
Reproduction of Death Registration Form
FORM B (Section 24)
DEATH REGISTRATION FORM
1. DEATH IN THE DISTRICT OF
2. PARISH 3. NO.
Do not writein this margin
3
4. PLACE OF DEATH USUAL RESIDENCE OF DECEASED
.................................................................... 12.(a) Residence ................ .......... ....................(b) Town or Viiage ... .... .. ........................... ..
.................................. .......................... ........ (c) parish .... ...................................,,, ...........
PARTICULARS OF DECEASED i3. CAUSE OF DEATH
5. Date of Death ................ ....................... ....0. I (Immediate Cause)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (a) ....................................................................
6. Ftd I&medue to................ .................... ...............
. ................... ............. ................... ................ (b) ........................ ............................................due to
7. Sex .............. 8. Condition ......................... (c) ...... ....................... ........ ..#...o...,,,..............0...
9. Age ....... years ....... months ............... ... days II (Contributory) ....... .................. .....................
10. Occupation or calling ....................... ........... ........................................... ...... .......... ...........
. .............................................. .... ...............$. 14. Certified by .................................0............0..
11.Birthplace ,,. ,.......$..,,,........ .. ........................ ................................... ... ..........................0...,Quakficufmn
INFORMANT
15. Names and Surname .................................... 17. (a) Residence ..... .......... ..............................
. ......... ..... ..................................................... (b) Town or Village ....... ..............................
16. Qualification ............................................... (c) Parish ....................................................
..... ............................................................................. .................. ........ ......*... .... .. .......................0Szgnature of Informant
REGISTRAR’S CERTIFICATE
18. (a) Signed in my presence by the said informant(or)
(b) Entered by me from the particulars on a Certificate received from ..................................,., .
........................ .......................................................................... .................... .............................
19. Witness ...................... .......... ........ ......b... ......20. Date ......................................... ...................
21. Signed .............. ................... ..... .......... .... ......Registrar
144
Reproduction of Medical Certificate of the Cause of Death
REGISTRATION (BIRTHS AND DEATHS) LAW, CHAPTER 337MEDICAL CERTIFICATE OF THE CAUSE OF DEATH
To be given by the Medlcd Attendant to the person whose duty it is to give it with information of the Death, to the Registrar of the District irrwhich the Death took place and TO NO OTHER PERSON.
I HEREBY CERTIFY that I attended ............................................................................................................................whose age was stated to be
. that I last say h..,............................,,..,,,..,.,,, , on the .............................. day of .......................................................... .... Id ... ...... . that ......... he Died*
,,,,.,,,,,, ,,,,0,.,,,... ,,,,,,.,,.,,,,,,.,,,,.,,. !!. on the .......................... day of .................... ............................................ .......................19. ........ . at..., ......................
,.......................................................................... arrd that to the best of my knowledge and belief the cause of h ......... death was as hereunder written.
CAUSE OF DEATHApproximate interd
between onset and death
*Should the MedicalAttendant not feeljustified in takingupon himself the re-sp~nsibfky of certi-$wrg the fact ofDeath, he may hereinsert the words “asI am informed.”
IDisease or condition directly
Years Months Days Hours
leading to deathtAntecedent Causes (a) ..........d . . ... ..y.i.l.i..qi.rii.r:q:.:q... . ............... . ................ .............. .. ...............
Morbid condition, if any, giving .rise to the above cause stating the
{
(b) ..........di~..~..q.~~..~.~j:~~;;.;~j.... . ............... . ................ ............... . ...............underlying condhion last
H (c) ........................................ .......................... ................ ................ ................ ...............Other sigri~lcant conditions con-
I
......................... ...... ........................................ ................ ................ ................ ...............tributing to the death, but not ........................... ............................................ ................ ................ ................ ...............related to the disease or condkioncausing it.
t’This does not mean the mode of dying, e.g., heart fsilure, aathenia, etc. Itmeans the disease, injury or complication which caused death.
Witness my hand this .......................................................... day Of............................................................. 19----tignature..o ...............................o............................................................ Registered Qualification .............................................................
Residence ................................................. .............................................
N,B.-TH1S CERTIFICATE IS INTENDED SOLELY FOR THE USE OF THE REGISTRAR to whom it should be delivered by the person givinginformation to him of the particulars required by law to be registered concerning the death. Penalty of Two Pounds for neglect of Informant todeliver this certificate to the Registrar.
The Regktrar-Generd cautions all persons against accepting or usirrg this certifkate for any purpose whatever, except that of delivering it to theRegistrar.
FOR USE BY PUBLIC INSTITUTIONS
CONDITION
(Married-Widow-Bachelor-Spinster-
Infant)
PARISH OF BIRTH RESIDENCE
OCCUPATION
(For married women or Widows–nameand occupation of husband)
For Legitimate children nsrne andoccupation of father.
For Illegitimate children name andoccupation of mother.
For Children under 1year enter here:–
Age of mother at timeof Birth and live-birth order of de-ceased child
145
ChapterVI
Viii RegistrationSystemsin Five DevelopingCountries:Honduras,Mexico,Philippines,Thailand,and JamaicaAComparativeStudy
BemldBe@alllin
CONTENTS
Introduction .............................................................................................................................................. 151
Core of the Problem .................................................................................................................................. 151
Basic Registration Function ...................................................................................................................... 152
Choice Between Central and Local Control ............................................................................................... 152
Registration Procedure .............................................................................................................................. 154
Medical Mmpower .................................................................................................................................... 155
Statistical O.ation ............................................................................................................................. 156
Users’ Requirements ............................... .................................................................................................. 157
Ttiting ................. ................................................................................................................................... 158
summary...................................................................................................................................................158
LIBT OF TABLES
VI-1. Charaftenstics of local officials responsible for registration: Honduras, Mexico, Philippines,Thalmd. adJmtim .................................................................................................................. 153
VI-2. Birth and death registration procedures: Honduras, Merdco, PWlppines, Thailand, and Jamaica .... 155
VI-3. Comparison of registration systems: Honduras, Mexico, Philippines, Thailand, andJarnaica ......... 157
149
CHAPTER VI
VITAL ‘REGISTRATION SYSTEMS IN FIVE DEVELOPINGCOUNTRIES: HONDURAS, MEXICO, PHILIPPINES,
THAILAND, AND JAMAICAA COMPARATIVE STUDY
Bernard Benjamina
INTRODUCTION CORE OF THE PROBLEM
This report is based upon a review of thefindings prepared by members of World HealthOrganization missionsb who visited Honduras,Mexico, Philippines, Thailand, and Jamaica inthe early months of 1977 to observe theoperation of vital registration. In summarizingthese findings, a primary purpose is the identi-fication of practical steps that might be taken,given the necessary resources, to provide earlyreduction of the deficiencies that were strikinglyapparent to the observers. In none of thecountries visited was vital registration evennearly complete. In all the countries the calcu-lation of vital rates could not be made withaccuracy; these rates could only be estimatedfrom national demographic surveys carried outindependently of the registration system.
aTemporary adviser, professor of actuarial science,City of London University, London. (Chief PopulationStatistickm, General Registrar Office of England andWales 1952-63.)
bThe missions were organized within the frameworkof the vital and health statistics programs of the World
Health Organization, the National Center for HealthStatistics, and the U.S. Agency for International De-velopment.
Apart from defects in the individual systEms,which will be commented upon later in thisreport, one serious obstacle to progress, whichmay be alleviated but cannot be cured quickly,exists; this is the fact that the countries are noteconomically fully developed.
Registration systems are only successfully “introduced at the stage of economic develop-ment when, simultaneously the demands of theeconomy both for statistics and for the personalprotection of registration provide strong motiva-tion and the capability of the economy isadequate to provide educated manpower andother resources to operate the system. It usuallyhappens that it is when the economy hasdeveloped to a point at which it cannot functionproperly without vital registration (if only tolink property or adjuncts to property, such asinsurance and people), that it finds it possible tosupport such a system.
This means that even if greater resources areprovided than would, in the past, have beenavailable, a country that is not yet economicallydeveloped is bound to face the problem of lackof personal motivation on the part of individualmembers of the population. This is not amotivation to provide vital statistics-probably
151
only a fraction of the population is ever likely totake a keen interest in birth and death r’ates-it isa motivation to obtain documents for personalidentification. The best dt?signed statistical sys-tems are likely to fail if this personal motivationis lacking. Thailand provides an example of acountry that has a well-developed and organizedregistration system but that still lacks thismotivation; birth coverage is only 85 pez’centcomplete, and death coverage, 70 percent,Jamaica is the exception that proves the rule.The upsurge in migration with its attendantdemand for regist.raticm documents has replacedeconomic development as a motivating factor,
This does not mean that nothing can bedone to make progress in q developing country.A determined government, which is itselfstrongly motivated, need not wait for history. Itcan. stimulate personal motivation in advance ofeconomic development, but it will not be easy.Motivation needs to be made a persistent prior-ity. Computers and systems analysts should,meanwhile, be ready and waiting to be calledinto service at the proper time. However, anyimprovement in the use of derived information(e.g., vital rates) as distinct from merely in-creased efficiency of their calculation, which isthe only gain from computers, may providesome improvement in motivation as interest isfed back from the users to the local officials andin turn to the community. Such improvementwiU, however, only be marjjmd.
BASIC REGKI’RA’I’ION tW?WTiON
In Honduras and Mexico, the act of regis~tration is a purely local function because there isno central body to exercise responsibility. In theother three countries, the responsiblit y forregistration is v~sted in a central governmentdepartment: in the Philippine, it is the NationalCensus and Statistics Office (the ExecutiveDirector is ex-officio Civil Registrar General)emphasizing, somewhat prematurely, it mightappear, that the main government interest is inderived information; in Thailand, it is theMinistry of the Interior, emphasizing the pri~mary identification role of registration (at thesta~ of deriving
152
information, ‘control switches
to the Department of Public Health, but this isbeyond the normal awareness of the ordinaryvillage or municipal informant); in Jamaica, theMinistry of Health and Environmental Controlhas jurisdiction over the Registrar General (al-though his position is weakened by the fact thathe is stationed 22 kilometers (about 14 miles)away from the Health Ministry and has nocontact with other central government depart-ments).
CHOICE BETWEEN CENTRAL ANDLOCAL CONTROL
~~re is a dual need for firm central controlof awl registration. First, it is necessary toensure that the law is properly administered andthat the personal purposes of civil registration,both on behalf of the individual citizen and onbehalf of the government, are fully achieved.Second, if basic registration is ultimately to beused for the production of vital statistics, centralcontrol is necessary to ensure that the primaryrecord is uniform in content and format and of aminimum quality to support usable nationalstatistics. The vesting of responsibility for pri-mary registration in a central government de-partment will normally be a prerequisite for theprovision and maintenance of standards byleading to an organizational structure that facili-tates the training of local registrars and thesupervision of their work. If these last condi-tions are not fulfilled, then central control losesmuch of i~s advantage. T& is illustrated by thesituation in Jamaica where the Registrar Generalhas only two supervisors to cover 380 registrars,and some local registrars have not been visitedfor several years; moreover, many of the localregistrars are postmasters, and others are privateindividuals who have set up offices in their ownhomes so that the absence of inspection andtraining is all the more serious. Central controlmust have the resources to ensure propercontrol.
The claim is sometimes made that localcontrol as opposed to central control brings theadminktrator nearer to the people. This doesnot appear to be an advantage. On the contrary,the absence of central control appears to open
the way to laxity and divergence of practice, ifnot actual failure. In Mexico and Honduras,where there is no central control, the personsappointed as registrars do not necessarily per-form the duties themselves, and neither they northose who serve as their deputies have anytraining in the purposes of civil registration; nordo they have any incentives to make registrationcoverage complete. (In Honduras, the Popula-tion and Migration Policy Board intends toestablish supervision of birth registration, butthis has not yet been arranged.) ,Central controlis expensive. It cannot be funded with moneyprovided by international bodies because thiswould give the appearance of interference withthe local official civil administration; it, there-
‘fore, depends on the willingness of the govern-ment to provide the resources from the nationalbudget.
Characteristics of local officials who areresponsible for registration in the five countriesunder consideration are presented in table VI-1.
It is clear that in all the countries visited theofficers appointed to carry out the duties of
primary registration are not selected because ofany special skill, are not provided with anytraining (apart from the provision of a manualand locally organized seminars in the Philippinesand the rare visits of an inspector in Jamaica),and, except in Jamaica, are not paid in such away as to encourage a vigorous pursuit ofcompleteness of coverage. Only in two of thecountries (Philippines and Jamaica) are theydirectly responsible to departments of the cen-tral government that have a particular interest incompleteness of coverage in the sense that thesedepartments themselves wish to obtain reliablevital statistics. Pressure to produce completevital statistics does not (as stressed in the section“Core of the Problem”) stimulate motivation inthe individual citizen, but it can do much tostimulate motivation in officials if that pressureis directly exercised by their employers. It maybe argued that this thesis is not supported by theexperience in Jamaica where the local registrarsare responsible to the central government de-partments that produce and use vital statistics.For both countries, however, the reasons are
Table VI-I. Characteristics of local officials respansibla for registration: Honduras, Mexico, Philippines, Theiland, and Jamaica
Characteristic
official ,,,,,..., . ... .. ... .... .. .. ... ..
Suparvlslon ..... .. .... ...O.. .. O.O..
hymnnt, .. .. .... .. ... ... ... .. .... .. .
Training .. ... .. .... . .... ... ... ... ... .
Respon$lbllity .. .. .. .. .. ... ... ... .
Hmrdurca
Municipal: registrareppolnted by depart-ment politicelgwernor (10 andmore municipalities toeach of 1S departments)
Rural eraas:auxiliary mayorappointad by mayorof municipality
Nil
No specific sslery.May exact additionaltaxes by charging, foraxemple, for burialpermit
Nil
,
Does not do all the work,but slgrrs certificates.Responsible throunh de-partmental govarnor totha Minister of theInterior and Justice
Mexico
Municipel: raglstrarappointed by murdcipalpresident (in MaxiooCitY, by civiljustices}
Rural areas:daputias appointed bymunicipality
Nil
Sslaried
Nil
Has to meet, considerablestatistical damsndafrom cantral Govam-ment. Responsible tocivil justices
Philippines
Municipal: local firsence
officar or city haalthofficer
Rural areas:
n’sinicipaliw”
Nil
No specific calary
Manual is circulated.Local seminars byNational Census andStctistic5 Office
Work done by designatedemployees. Rewonsibleto National Censusand Statistics Office
Thailand
Municipal: appointed byMinister of Interior
Rural: villageheadman responsiblethrough communeheadman to districtofficer
Nil
Spacific payment notmentionad in report
Raspmrsible toMinistry of thaInterior
Municipal: appointad by
Ragistrcr-Genaral inMinistry of Healtha~~twmantal
Rural: as almva
Negligible. Only 2inspectors. Some localoffices not visitadfor years
Paid by fees fromcantral gwernment
Only training is by the2 inspectors-covsrmevery incomplete
Actually does the Work,is peid by results.Responsible toMinistry of Healthand EnvironmentalControl
153
simple—too high a staff turnover in the registra-tion service of the Philippines, and in both thatcountry and Jamaica an inadequate exercise ofthe kind of direction and supervision that isessential for any feedback of motivation.
It is recommended, therefore, that localregistrars should be appointed, supervised, andtrained by officials of specific offices such asthat of the Registrar General situated withincthe Ministry of Health or by an official of theNational Census and Population Statistics Of-fice; that ‘they should be selected on thebasis of their pkior understanding of at least thepurposes and mechanisms of registration and anelementary knowledge of the production anduses of vital statistics; that they should be paidspecifically for their duties (and for their work-load) and their careers should be structured soas to encourage a spirit of vocation. (Furtherreference is made, later, to training.)
This would undoubtedly increase the overallcost of registration in comparison with presentlevels of expenditure, but this increase wouldnot be great. It would, however, be cost effec-tive. A part of this increase in cost would bemore apparent than real because expenses thatare currently covered by local budgets (probablynot always visible in accounts) would be trans-ferred and made more explicit in the nationalbudget. In addition, complaints, such as the oneby the local registrars in the Philippines thatbecau:e of dependence on local funds they areunderstaffed, poorly equipped, and inaccessible’to the population, would not be possible.
REGISTRATION PROCEDURE
In aIl the five countries, personal factspertaining to a vital event are given to theregistrar by a person who was present at theplace of occurrence of the event and who isdefined by law within a chain of responsibility
cThis means physical location in the office of the “HealthMinistryand in close daily contact with seniorcolleagues who need vital statistics. In Jamaica, the Regis-trar-General’s Office is part of the Ministry of Health andEnvironmental Control but is isolated in a separate office.See “Basic Registration Function.”
extending from immediate and responsible rela-tives to attending health care personnel andfinally to some persons who “have knowledge”of the event. (Curiously in the Philippines, forbirths, the attending physician or the clinicadministrator takes priority over the parents.) Itis essential that there should be such a chain ofresponsibility, but it is essential that it should bereinforced by the imposition of a penalty onfailure to report. In all the five countries, thepenalties are either slight or only infrequentlyimposed in practice. All the countries experiencea high incidence of late registration. Furtherdetails are summarized in table VI-2.
It would appear that because there is a lackof local funds registration is made more difficultfor the general public. Offices are frequentlysituated far from the home of the informant andare often understaffed and ill equipped; in-formants, therefore, are inconvenienced byhaving, to wait in lines. Presumably because oflack of staff and lack of career incentives, thelaw relating to the time limit for registration andto the withholding of a burial permit is notfirmly applied. As a result, registrations areneglected or often delayed.
In addition to the improvements in condi-tions proposed under “Choice Between Centraland Local Control,” efforts should be made tohelp informants carry out the process of registra-tion. Steps should also be taken to make themaware of the necessity for registering the events(for example, there should be no exception tothe requirement that a death be registeredbefore a burial permit is issued). The require-ment of witnesses, as in Mexico, seems to be anunnecessary complication and possibly a deter-rent. The presentation of birth certificatesshould be made mandatory for as many impor-tant civil purposes as possible-education, em-ployment, migration, and so forth. The publicmust be made to realize that there are realmaterial advantages to registration. In countieswhere public transportation systems are unde-veloped, 10 kilometers (about 6 miles) is a longway to go to a registration office, and, inaddition, waiting in line can be a major dis-couragement. The aim should be to reduce thedifficulties and to increase the advantages ofregistration in whatever way possible.
154
-–-.., .–. –., ,–––..
Registration procedure
Who reglners?lBirth .. ... .. ... .. ... . ... ... .. .. .. .Deeth .,,,.,,..,,.,,,.,,..,,,,,.,.
who the Is Preeent?z .,,,,,,,.
3upporting documentsrequired .. ... ... .. .. .. ... .. .. .. ...
Time limit forr2g19tratlon:
Binh .,,,,,,,,,,,,,., . .. ... . ... .. .
Death ,.,,,, !.. !.,., .. .. ....0.,,,.
Doaummte given to
inf0m8nt,,.,,,,,.,,,.,,.,..,,,,,
Prlnelpel defecmGmsmal .,,,,.,..,,.,,,.,.,,,,.,,
Birth ..,.,..,..,,,.,,,,,.,.,,.,.,.
Teeth . .... .. .. .. .. ... ... ... . .....’
Table Vi-2. Birth andderrth rwistretion prmedures Honduran, h4exico. Philip
Honduras
parentsNearest relative
2 wltnwses
Not specified
8 &VS
24 hours
Certificate of registra-tion details
Registers are notpre-printed eo registrar hasto depend on mamoryfor Iagel formula
Long delay
Onlv 13 percent of da.ethsregistered are medicallycertified
Certificetee not elweysgivenby hoepiteltorelatives
Burial permit can h ob-tained without proofof registration
Early infant deaths notregistered as births
Mexico
ParemtsNearest relative
2 witnesses
Certifiaete of Daeth
15 days (father)40 &y’s (~other)
Not stated
Certificate of registra-tion details
Not stated
Long delays (fineslenient)
If body rranefe~rad forburial in another area,it can be registeredtwice
Burial permit can be ob-teirred without regime.tion in some circum-stances
lgee .Im llRe@ation prncedure!~ for chehr of responsibtity in rS@StrltiOn Pr~eSS.21n ●ddltlon to inforrerent and rWhtreI.~gea ,IW ,*Cholce Between Locel and COntrSl COntfOl.”
MEDICAL MANPOWER
A major difficulty, especially in death regis-tration, is the lack of medical attendance at thevital event. In the Philippines, three-quarters ofall births take place outside a hospital andone-seventh of all confinements take place athome without any medical attendant; the cor-responding proportions in Honduras and Mexico-.are probably higher. Again in the Philippines,one-third of deaths are not medically attended,and the proportion is substantial- elsewhereexcept possibly in Jamaica. In these circum-stances, the production of statistics on cause of
Philippines
Birth attendant and perent!Neare$t relative
No one
Prior notificetinn *
attendirrg physicien
30 days
48 hnure for repnrt toled heelth offiie,Wch orders registrationwithin 30 days
Certificate of regiatre-tion demils
Inadequate etetiOnery.3
Incomplete
Incomplete
Burial permit giwn orrdeath notification andthnugh reghtretion isordered to be dnnewkhin 30 *ye, it isnnt akys done.
Thailand
parentNeereatrelative
Not stated
CMtificetaof Death
15 dcys
Not stated
C8rtificete of registra-tion details
Not Stid
Incomplete
.lemeice
parentNearest ralative
No one
For birth, notifiition
sigmed by motherFor decth, certificate
of daath
42 deYs (midwife requiredto notify within 48hours)
5 days
Certificate only that eventhea teen registered. Notgenerally acaapted asevidence of birth
Time limits nnt vigornudyapplied. Same officeeremote
Delays
Delays
Burial permit given oncertifiite of rW”s-tration lwt 7 percentunderregistretion exieta
death, a major national health indicator, isimpossible. -
The prospect of an immediate expansion ofmedical manpower is minimal. If it were prac-ticable (there are not enough medical schools), itwould be expensive. However there is a clearopportunity here for the extension of thegrowing practice of employing partially trainedmedical assistants to make a broad and possiblysymptomatic rather than a systemic categoriza-tion of cause of death. An experiment alongthese lines is being made in Honduras where“health guardians,” who are volunteers in ruralcommunities, are trained to deliver primary
155
health care and to refer patients whom theythemselves cannot treat to rural health centers.It is not ,clear whether or not they actuallyattribute a cause of death, but there seems to beno reason why they should not do so. Presentlytwo major defects in the experiment are ap-parent: There are too few health guardians(10,000 are needed, but there are only 300), andthe information they gather remains at the ruralhealth centers because no organization has yetbeen set up to incorporate these data into thenational data collection system.
The institution of experiments of this kind is‘ possibly an activity to which extranational fundscould be legitimately applied, for example, fromthe United Nations Fund for Population Activi-ties or from international foundations, withoutpolitical embarrassment. It would be one impor-tant and effective way in which counties couldbe helped to overcome their lack of economic.development stressed in the section “Core of the ~Problem” in this chapter.
Any experiment of this kind should not bere~arded as simply of interest to health statis-ticians, but should embrace the national registra-tion service whose members should be led toappreciate that the objective is to improve basicregistration coverage and completeness. If thelocal registrars could be involved and, moreespecially, feel involved, it would be a consider-able boost to their morale. It should be aregistration and not just a statistics “thing.”Indeed, some of any money provided should bedevoted to holding seminars for’ registrars todiscuss the experiment’s progress and ways ofimproving registration.
STATISTICAL ORGANIZATION
This topic has been left until the last for avery important reason. The health statistician ismainly and legitimately interested in the produc-tion and utilization of reliable vital rates asprimary national health indicators, but heshould not make the mistake of thinking thatthis is the primary objective of vital registration.It is not. Vital statistics are a valuable result ofregistration, but they are not the central objec-
tive. Complete and adequate registration as anobject in itself is, however, a precondition of theconstruction of a reliable vital statistics system.To improve vital statistics, the major effort mustbe directed toward improving the registrationsystem.
As already indica~ed in “Choice BetweenCentral and Local Control” in this chapter,there is some feedback of motivation to theregistration system. This does not come fromdemanding that registrars should give moredetailed statistical returns more often. On itsown, such pressure is likely to be counter-productive. Motivation can only come fromstatistics being used and being seen to be used insome way that will benefit health services oreconomic development generally. It is impor-tant, therefore, that any training programs insti-tuted for registrars should include not so muchthe methodology of vital statistics as a cleardemonstration of the use of vital rates in healthadministration, population projection, ‘man-power planning, and for other economic pur-poses. In none of the five countries visited doesthis happen at present. In all five countries, a#eat quantity of paper moves from office tooffice; there is even talk in the Philippines andThailand of the development of health manage-ment information systems,d but nowhere arereliable estimates of vital rates being produced.
What is more important than talk of systemsanalysis is the insistence upon a single clear lineof communication of primary data to a singlefocus of vital statistics generation and that thisfocus should be within the central governmentdepartment where those statistics will be mostused for administrative and, above all, forpolicymaking purposes.
The five systems may now be compared asshown in table VI-3.
Instances exist of two or more departmentsof the central government collecting and proc-
‘Such systems only work if there is a real point ofentry of basic information (in this case, reliable registra-tion) and a real point of extraction for management (ona conversational basis). They imply the existence ofsophisticated forms. of management, which arc notappropriate to developing countries where the systemscould remain elegant but unused.
166
Itcm
fAdium of tmn:fm ofprlmcry information .... ...
Rout@ to national dctaprocctsing ,,,,,,,,..,.,,,,.,,,,..
C4ntrd gowrnmwttdepwt.mmt that processes.......
Othw dcpartmmtsWvlcod,.,,.,,..,.,..,,,,.,..,,,..
Melnpubli$hw...................
Avmgs timo lagforpublication ., .... .... ..... ..... ..
Rdlabllltv ... .... .... .. .... .... .... .
Tabk W-S. Corn
Hondumc
Smtisticcl summwy ofoech registmtion sentIn bundles wneklv
Dlrcct
Gerwal Steti$ticc ●ndCensus Offiw (part ofMlnistw of Economy)
Ministry of Public Heelth,Highw EconomicPlanning CXwrcil
Scmarel Board of Sta-tistics and Censuses
I veer
!40 wrificatl on: operatesIW rule.af.thumb forfilling omitsions
3wcd on rogistratlont inperiod not wcnts
3wcd on phC* of OCCUr-renw not resldmce
ikon of registrationRVM
Msxko
Stctitticcl wmrnwim inmrnthlv bomhe$fbvSthd6v of followingmonth )
viaStatoofficeofDirwtor4tc Genemlof Sxctiatic$
>imqtomtcGonwelafStctistict (pm ofDeportmentof Pro-~mming and Bu~t)
Xpwtmant of Hmlth 8ndWelfare (C3imotomt~General of fliottatistics),N@tionalFowl#tionCouncil,W“xiocnIntthtwo of SW191S6@tv
hp6rtment of Hwlth●nd Wdfwo
I Vmre
IOnwcrwfewrificmion atIocclStett offiG9sOfDirectQratcGcnwd ofSmtistict
keel on mgi$tmtionsinPsriod not ewnft
le~d on plwe of 00cur.mncc not residence
lFor ,ummUY ~Bure$ only. Detsiled ●nalyseshavenot beenpubli:hcddnce 1964.
msing primary data independently of eachother. This is obviously wasteful of statisticalmanpower, which is in short supply. Apart fromthis, the statistical systems seem to be reason-ably efficient. It would probably lead to someimprovement in the quality of the data if thedepartment that is the main user (e.g., Ministryof Health) were also the department that proc-esses and publishes; there could then be moreeffective feedback. Some drudgery could prob-ably be removed by the more effective use ofcomputers, but experience suggests that thiscould mean an increase in costs. Priority for anyextra money should, at this time, go to the
improvement of the quality of primary registra-tion. More improvement in data processing is ofno avail to repair deficient primary data,
Fililippilw$
QIMIIicsfc copic$Wthlv(in first 10 *S offollowi~ month)
W regiotrsloffii ofNetierul eontw andStmistlm Office
,N@t@nRl Conws md
Stmtkt Office
0m6mmt of Hmlth
Mtiond Cen#ut andStati$tkl Offim
sW6rt
Swd or! mgktmtiom inpwiod nor wcnts
Mwd on PICCOof ocour.rencc cot r8si*nce
TMIwrd
S@tistk61 P9rt of qi$,trq;ion form sent monthly(W Sth *V of followingmomfrl
Sumcrwiz4dat FvOVincidOffii of M/rfittcy of tfmIntqrimr+urwnwv notprigind form toMini~W-originals tetMini$fw @f Publiri H@cl!h
Mitfiltwof PuMiG
H@fr
Minlatrvof tfw Irmrior
Minixtrv of PubIii No61th
3 v~a
some Iood CFmcke
BatedWI @W Of OCCUr.rcncc nor refidcnce
Cop@ of rqistmtionfom$
IWtrkt offiw6 of [email protected] Gcncrcl (MinisWof Halth snd f3wiron-nwntel Control)
Fcrtlv Mlnittry of Fincnw(Chpufmcntof St4ti8tics) .8nd Ministryof Halth(RogiatrcrGwr@), butdso other orgmizatiorrs
Mini$tryof H.elth, F6milvPlwtninSBoard,N@tiorrclPlccrnirqASEnCV
Ministwof Finmtw,Ministrvaf Nwlth andl%wiramncntel Control
f Vw 1
Bccoc=oJmldrrg in district
Mtedonwentr
Carected for residence
USERS’ REQUIREMENTS
In terms of statistics, the main users are:
Economic phmncrs who require reliable andup-to-date vital rates (including specific fer-tility rates) for the measurement of changesin the population structure and especiallyfor population projections
Health service planners and administratorswho require indicators of the health state ofthe population as a means of assessing theeffectiveness ~f delivery of health care imdthe future tasks of the health services.
The latter users especially need Whiit, bc-causc of deficient registration, they cwmot now
157
have, that is, good cause-of-death statistics. The to encourage others, a meeting of local registrarsobstacles have already been discussed in this to discuss the law, the practice, and the day-report. to-day problems that arise. In these meetings,
vital statisticians should be present to expresstheir needs, but their intervention should be
TRAINING minimal.
In most of the countries visited, there aretraining courses for the users of vital statistics(in Mexico, a plethora of courses); but there isvery little, if any, training available for primaryproducers. For example, it is important. thatmedical students should have some training invital statistics so that they will understand theneed to specify correctly the cause of death. Ifthe death is not registered properly or not at all,there still will be no vital statistics.
In Scotland, prior to 1960, it had long beenthe custom for the local registration junior staffto take a written examination in registrationpractice. The Registrar General for Scotland hadrecognized this examination, and the local urbanauthorities who actually appoint registrars (reim-bursed by the central government) had takenthis into account in making promotions to theoffice of registrar. In 1960, the registrars formedthemselves into a professional organizationcalled the “Institute of Population Registration”with a training program, a technical journal, anda system of examinations leading to qualifica-tion. The Institute has done a great deal to raisethe educational level of the registration serviceand also has introduced its members to widerhorizons, for example, to a study of registrationproblems in other countries and to a betterunderstanding of their role as population infor-mation officers (normally the registrars becomelocal census officers during a population census).
Without suggesting that this development isnecessarily appropriate to developing countries,it is proposed that experiments should be madeto bring registrars closer together both withincountries and between countries. A beginningmight be made by (1) arranging a regionalmeeting between senior registration officers ofthose countries that have a vital registration lawand senior administrators of those who do not asyet have a registration system to discuss theproblem of obtaining complete registration and(2) arranging in one or two countries, primarily
SUMMARY
The vital registration systems in the fivecountries have been shown to have many de-fects, many of them arising from the country’slack of economic development. These defectsare:
A lack of incentive to register on the part ofthe public and a lack of encouragementand/or compulsion to register on the part ofthe government. Registration is incomplete,late, and inaccurate.
Insufficient medical certification of deathmainly because of a lack of medical man-power. Cause-of-death statistics are, there-fore, inadequate.
Lack of training, supervision, and encourage-ment of registrars. A subsidiary failure is thelack of standard rules of practice, concepts,definitions, and so forth.
Delays in aggregation of records and indissemination of statistics.
In some cases, a multiplicity of discrepantpublications.
It is suggested that stronger centralization ofthe registration system with a single focus ordirection and assembly of information wouldlead to improvement and would not necessarilyrequire extensive additional resources; that moremedical manpower is needed and that this mightbe supplemented experimentally by medicalassistants not fully trained; that medical stu-‘dents need more education in vital statistics,their derivation and use; that, above all, at-tempts should be made to raise the esprit decorps of the local registrars by providing anadequate career structure, by improving com-munication between registrars, especially in the
158
discussion of working problems, and by makingthem feel more involved in the worthwhileprocess of measuring population change andpublic health trends; that communication shouldbe extended to the internatiomd level; andfinally, that given an improved organization,more effort is needed to increase the incentivefor ordinary members of the public to registerthe vital events of which they are the responsibleinformants.
In this report, emphasis has naturally beenplaced upon the need for national governmentsto make a greater effort to promote effectivevital registration systems, However, a number ofother subsidiary suggestions have been madethat might alleviate specific difficulties andcould be implemented extranationally if thenecessary external ji’nancial aid were forth-coming. These are recapitulated here:
Tlie conducting of regional workshops ofshort duration in which senior officers in theregistration services of a number of countriesfairly close together could come together todiscuss the problems besetting vital registra-tion and the possible ways of overcomingthese problems. The problems to be dis-cussed would include the basic organizationfor vital statistics preparation and publica-
tion. Outside experts from countries withexperience in overcoming problems in thedevelopment of compIete registration cover-age and reliable vital statistics would attend.
The preparation of teaching material thatcould be used within an individual de-veloping country to instruct operating staffin the nationaI vital registration system. Thismight take the form of a manual forinstructors of vital registration staff.
The supply of audiovisual aids so thatteaching material can be prepared.
The offer of a technical expert to examineparticular national situations especially thosewhere, because organization is complicatedand responsibility is divided, the availableprimary vital registration information doesnot find its way to effective analysis andpublication, Such an expert should not be astatistician or a computer systems analystbut, rather, a person with knowledge of allstages in the organization of vitaI statistics,from initial registration to final printing oftabulations. Such experts would need vastexperience and great tact and humility but,given these qualities, they could be ex-tremely effective trouble shooters.
,
MM, GOVERNMENTPRINTING OFFICE: 1981 341-161/30 1-3 159
VITAL AND HEALTH STATISTICS Series
Series 1, Programs and Collection Procedures. –Reports which describe the general programs of the NationalCenter for Health Statistics and its offices and divisions and data collection methods used and includedefinitions and other material necessary for understanding the data.
Series 2. Data Evaluation and Methods Research. –Studies of new statistical methodology including experi-mental tests of new survey methods, studies of vital statistics collection methods, new analyticaltechniques, objective evaluations of reliability of collected data, and contributions to statistical theory.
Series 3. Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and healthstatistics, carrying the analysis further than the expository types of reports in the other series.
Swim 4, Documents and Committee Reports. –Final reports of major committees concerned with vital andhealth statistics and documents such as recommended model vital registration laws and revised birthand death certificates,
Series 10. Data From the Health Interview Survey, –Statistics on illness, accidental injuries, disability, use ofhospital, medical, dental, and other services, and other health-related topics, all based on data collectedin a continuing national household interview survey.
Series 11. Data From the Health Examination Survey and the Health and Nutrition Examination Survey .–Datafrom direct examination, testing, and measurement of national samples of the civilian noninstitu-tionalized population provide the basis for two types of reports: (1) estimates of the medically definedprevalence of specific diseases in the United States and the distributions of the population with respectto physical, physiological, and psychological characteristics and (2) analysis of relationships among thevarious measurements without reference to an explicit finite universe of persons.
Series 12. Data From the Institutionalized Population Surveys. –Discontinued effective 1975. Future reports fromthese surveys will be in Series 13.
Series 13. Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilitiesproviding long-term care, ambulatory care, hospital care, and family planning services.
Series 14. Data on Health Resouzces: Manpower and Facilities. –Statistics on the numbers, geographic distri-bution, and characteristics of health resources including physicians, dentists, nurses, other healthoccupations, hospitals, nursing homes, and outpatient facilities.
Series 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthlyreports. Special analyses by cause of death, age, and other demographic variables; geographic and timeseries analyses; and statistics on characteristics of deaths not available from the vital records based onsample surveys of those records.
Series 21. Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce otherthan as included in regular annual or monthly reports. Special analyses by demographic variables;geographic and time series analyses; studies of fertility; and statistics on characteristics of births notavailable from the vital records based on sample surveys of those records.
Series 22. Data From the National Mortality and Natality Surveys. –Discontinued effective 1975. Future reportsfrom theie sample surveys based on vital records will be included in Series 20 and 21, respectively.
Series 23. Data From the National Survey of Family Growth. –Statistics on fertility, family formation and dis-solution, ,farnily planning, and related maternal and infant health topics derived from a biennial surveyof a nationwide probability sample of ever-mamied women 15-44 years of age.
For a list of titles of reports published in these series, write to: Scientific and Technical Information BranchNational Center for Health StatisticsPublic Health ServiceHyattsville, Md. 20782
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