Despite the data gaps identified in this analysis, significantly more information on mortality of populations in the Pacific is available than currently used (Table
). Findings suggest that while significant investment is required to improve capture of cause-of-death, it should be possible for all the countries reviewed to be able to generate reliable data on mortality level within 4–5
years. Causes of death reported by nurses are currently of limited value due to use of broad categories and high proportions of "ill-defined" causes. The current system is appropriate to record only demographic aspects of death, unless procedures such as verbal autopsy [44
] are introduced. This should be considered for systems such as Kiribati, Solomon Islands and Vanuatu where universal medical certification is not currently feasible. All of the health department reporting systems reviewed were affected by problems with data extraction, duplicate data sets, coding and data entry issues and difficulties accessing records in the database that adversely affect data quality.
Legislation requiring registration of deaths exists for all islands, but does not necessarily reflect current practices. Health departments are carrying the bulk of responsibility for supporting routine data collection and civil registration functions, and their importance cannot be overemphasised. Efforts to improve data collection, use, and acceptability to decision makers will need to either focus on these systems, or ensure their integration into official reporting processes. A clear strength in all countries reviewed was the close interaction between health staff and local communities, including the opportunities this creates for building strong reporting relationships at the local level.
Significant duplication of data collection and entry exists across all systems, reflecting issues with data ownership, obsolete and unresponsive technology and fractured management of the reporting systems. The assessment identified three critical human elements that influence the effectiveness of civil registration and vital statistics operations. These are responsibility, authority to effectively undertake assigned responsibilities, and ownership or the value that staff place on the reporting system and their role within it.
The approach used in this study shares many similarities with the comprehensive assessment tool for vital statistics systems developed by researchers at the University of Queensland and WHO [19
] which is primarily a policy tool that aims to lead countries through a critical self-appraisal of their systems as a basis for developing a planning document for system improvement. The framework presented here was developed from a similar history, however is intended to provide a structured critical evaluation of system characteristics to inform the interpretation of available and published data from the region, yet also allows findings to be used in a policy setting to guide decisions around future system improvements required. Although conducted in partnership with the Ministry of Health and Bureau of Statistics, and through close collaboration with other local partners; the assessment reported here was led by researchers external to the systems being evaluated. This could potentially result in less ownership of the findings by those in a position to effect system improvements. However this approach allows an assessment by objective observers, with a broad range of experience across different reporting systems, and using a standardised framework; thus subsequently allowing for a regional comparison and for common themes to be distilled from individual country data. Further, this approach allows staff at all levels to discuss their views privately, and provides an opportunity for in-depth review where resources may not otherwise be available.
While many of the systems reviewed were highly complex, the framework used in this study provides a useful means of identifying themes for further consideration. This paper is designed to provide an insight into the mortality and cause-of-death reporting in the region. Several of the issues are identified here for the first time. Although previous studies have been limited, the issues raised are consistent with those noted in this assessment. These include little incentive to register vital events [45
] particularly in the case of children [46
], a lack of any “attempt to estimate and correct for under-enumeration” [2
], and referral biases in cause-of-death analysis due to the reliance on hospital data in the absence of robust community based reporting [47
Across the region, both registration and statistics systems need strengthening to improve the access, completeness, and quality of data. Close interaction between health staff and local communities provides a good foundation for further improvements in death reporting. Suggested priorities to strengthen systems are noted in Table
. Addressing issues of authority and support, and reducing the duplication of functions across systems would assist in alleviating resource pressure. Longer term priorities relate to broader shifts in practice and would require significant investment.
Key Regional Priorities for Action
System strengthening activities must focus on elements such as clear assignment of responsibility, provision of appropriate authority to perform assigned tasks, and fostering ownership of processes and data to ensure sustained improvements. These human elements need to be embedded in a culture of data sharing and use. Although there are common priorities for system improvement across the region, the diversity of infrastructure, social context and existing system capacity will require action to address priorities to be locally appropriate. Governments and international agencies should also support the use of local data wherever possible. Lessons from this multi-country exercise would be applicable in other regions where vital statistics systems are similarly characterised by duplication, inadequately trained staff, and poor use of good quality data on births and deaths in informing policy decisions.