An update

on Civil Registration System,

Sample Registration System &

Annual Health Survey

BHASKAR MISHRA

DEPUTY REGISTRAR GENERAL

Office of the Registrar General, India

25th September 2012

OUTLINE

• Civil Registration System- Current Status, Challenges and initiatives

• Key Results from Sample Registration System

• Highlights from the baseline survey of Annual Health Survey

Civil Registration System- Why?

• A complete & up to date CRS can provide reliable statistics on fertility & mortality along with their co-variates at all level of aggregations, almost on a real time basis, which is not possible from any sample survey.

• CRS as the key for evidence based planning has no parallels and levels of registration reflects the quality of governance.

Civil Registration System (CRS)- Key Features

• Registration of Births and Deaths falls under the Concurrent list of the Constitution.

• Registration of Births, Deaths and Still births in India mandatory with the enactment of Registration of Births and Death Act (RBD Act), 1969.

• Registrar General, India unifies and coordinates the activities of the States

• States are responsible for implementation of RBD Act.

• National Population Policy mandates cent percent registration.

• LOR(Birth) – India: 59.5% to 76.4 % ( + 16 %)

• LOR( Death)– India 52.1% to 66.4% ( + 14%)

• 12 States/UTs have achieved 100% registration of

births.

• 5 States/UTs have achieved 100% registration of

deaths

• Performance of Uttar Pradesh & Bihar remains the

main concern.

Registration Scenario in India during last 6 years

56.8 56.2 58.0

59.5 57.7

60.4

62.5

69.0

74.5 76.4

50.0 48.7

52.2 52.1 53.5

55.2 55.0

63.2

69.3

66.4

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Level o

f R

egis

trati

on

(in

%)

Year

Level of Registration of Births and Deaths, India, 1999-2008

LOR (Births) LOR (Deaths)

Still every 4th birth & every 3rd death goes un-registered

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Births 65.0 70.3 73.1 81.5 72.8 77.6 78.3 84.3 86.3 89.2

Deaths 55.5 60.2 61.9 69.6 67.4 69.8 69.0 72.7 73.7 73.2

65.0

70.3

73.1

81.5

72.8

77.6 78.3

84.3 86.3

89.2

55.5

60.2 61.9

69.6 67.4

69.8 69.0

72.7 73.7 73.2

50.0

60.0

70.0

80.0

90.0L

ev

el

of

Re

gis

tra

tio

n (

in %

)

Year

Performance of Level of Registration , India, 1999-2008, excl. UP & Bihar

Births Deaths

UP & Bihar suppresses the National LOR for Births and Deaths by 13 & 9 % points respectively.

Challenges

+ Awareness among the public about the need of birth &

death certificates - a cause of concern.

+ States/UTs are functioning at different level of efficiency.

+ Besides registration, problems also lies in timely

reporting (Registration takes place but it’s not reported).

+ Netting of infant deaths and misclassification of maternal

deaths remains a concern in better performing States like

Kerala and Tamil Nadu.

+ Delay of about 2-3 years in preparing the State level

Statistical Reports mars the utility of data.

Recent Initiatives to re-vitalise the system

+ Ministry of Health has made registration as one of the focus areas under NRHM. + Delivery of services are being linked with registration. + Provisions of the Act are being simplified for better implementation. + Supreme Court’s directive for revamping the system. + Updating of National Population Register linked with CRS at the sub-district level. + ORGI to collaborate with various partners to provide requisite boost.

Introduced in early 1970s to provide cause-specific

mortality profile.

Restricted to urban areas, that too few selected hospitals

At various stages of implementation across different

States.

Coding is as per ICD-10.

Covers about 19% of the total registered deaths only

Garbage codes(R00-R99) are to the tune of 15%

Medical Certification of Causes of Death (MCCD)

ORGI has expanded the scope under MCCD to all Institutions including individual practitioners and the coverage , extended to rural areas as well.

Sample Registration System – An Overview Introduced as an interim system in 1969-70 due to deficient CRS

Key features

o Fixed panel survey and a dual record system

o Reliable and continuous estimates

o State level estimates separately for rural/urban on

• All indicators of fertility and mortality including birth rate, death rate, IMR, Maternal Mortality Ratio, TFR, etc

• Under 5 mortality rate also generated from 2008 annually

• Panel revised once in 10 years based on Census frame

Current Panel of SRS (2004)

o Covers 4433 rural and 3164 urban areas (1.3 million households and 7 million population)

o Sample size determination based on IMR

o Permissible level of RSE: 10% (bigger states)

• Of the 8 MDGs, IMR, U5MR and MMR are generated by SRS.

Goal No.

Goals Indicators Targets by 2015

4

Reduce infant mortality

Infant Mortality Rate (IMR)

28

Reduce child mortality

Under 5 Mortality Rate (U5MR)

42

5 Improve maternal health Maternal Mortality Ratio (MMR) 109

MILLENNIUM DEVELOPMENT GOALS(MDG)

• IMR measures number of infant ( < 1 year) deaths per

1000 live births.

• Every 6th death in India pertains to an infant

• IMR in India has registered a 3 points decline to 47 in

2010 from 50 in 2009.

• Still, 1 in every 21 infants - National level, 1 in every 20

infants - rural area, and 1 in every 33 infants - urban area

die within one year of birth (against 1 in 37 under MDG)

IMR ESTIMATES 2010

80

74

68

58

47

86

80

74

64

51 50 48 44

40

31

20

30

40

50

60

70

80

90

1990 1995 2000 2005 2010

Total Rural Urban

Since 1990, IMR at the National level has declined by 33 points (1.65 points annually) against 35 points( 1.75 points annually) in Rural Areas and 19 points( 0.95 points annually) in Urban Areas.

80 74

68

58

47

78 73

67

56

46

81 76

69

61

49

-

10

20

30

40

50

60

70

80

90

1990 1995 2000 2005 2010

Total Male Female

Female infants continue to experience a higher mortality than male infants

IMR ESTIMATES BY RESIDENCE & SEX 1990-2010

53

48 44

37 33

57

52 49

41

36

31 29 27

23

19

10

20

30

40

50

60

70

1990 1995 2000 2005 2010

Total Rural Urban

NNMR for the Country declined by 20 points (rural NNMR

by 21 points vis-à-vis urban NNMR 12 points) in the last 20

years at an annual average decline of about 1 point.

Rural-Urban Gap in NNMR is narrowing.

NEO-NATAL MORTALITY BY RESIDENCE 1990-2010

80

74

68

58

47

53

48 44

37 33

27 26 23 22

14

-

10

20

30

40

50

60

70

80

90

1990 1995 2000 2005 2010

IMR NNMR PNNMR

• Share of NNMR in the overall IMR is increasing over the

years (54% in early 70s to 67% now)

• Interventions are required to effectively curb NNMR

IMR Vs. NNMR Vs. PNNMR 1990-2010

• U5MR denotes number of children (0-4 years) who died

before reaching their fifth birthday per 1000 live births

• U5MR for the country has declined by 5 points over 2009

(59 in 2010 against 64 in 2009)

• A uniform decline of about 5 points is seen in male and

female U5MRs.

U5MR ESTIMATES 2010: HIGHLIGHTS

U5MR for the country declined by

59 points (rural IMR by 62 points

vis-à-vis urban IMR 33 points) in

the last 20 years at an annual

average decline of about 3 points

118

98

85

77

59

128

111

98

85

66 71

67

55 49

38

20

40

60

80

100

120

140

1990 1995 2000 2005 2010

Total Rural Urban

11

8

98

85

77

59

11

0

96

84

72

55

12

6

11

0

95

82

64

-

20

40

60

80

100

120

140

1990 1995 2000 2005 2010

Total Male

Male-female mortality

differential has narrowed down

over the years, yet the gap

remains significant

“ Child deaths are falling, but not quickly enough to reach the MDG target”

U5MR BY RESIDENCE & SEX: 1990-2010

• MMRatio measures number of women aged 15-49 years dying due to maternal causes per 1,00,000 live births.

• Decline in MMR estimates in 2007-09 over 2004-06: – For India: 212 from 254 (a fall of about 17%)

– In Empowered Action Group (EAG) states & Assam: 308 from 375 (18%)

– Among Southern States: 127 from 149 (15%)

– In Other States: 149 from 174 (14%)

• States realizing MDG target of 109 have gone up to 3 with Tamil Nadu & Maharashtra (new entrants) joining Kerala. Andhra Pradesh, West Bengal, Gujarat and Haryana are in closer proximity to achieving the MDG target.

MMR ESTIMATES 2007-09 : HIGHLIGHTS

Maternal Mortality Ratio (MMR); India, EAG & Assam, Southern States and Other States, 2004-06 and 2007-09

India & Major States MMR

2004-06

MMR

2007-09

INDIA TOTAL 254 212

Assam 480 390

Bihar/Jharkhand 312 261

Madhya Pradesh/Chhattisgarh 335 269

Orissa 303 258

Rajasthan 388 318

Uttar Pradesh/Uttarakhand 440 359

EAG AND ASSAM SUBTOTAL 375 308

Andhra Pradesh 154 134

Karnataka 213 178

Kerala 95 81

Tamil Nadu 111 97

SOUTH SUBTOTAL 149 127

Gujarat 160 148

Haryana 186 153

Maharashtra 130 104

Punjab 192 172

West Bengal 141 145

Other 206 160

OTHER SUBTOTAL 174 149

TREND IN MMRatio- India

(2004-06)

2009

2007-09 SRS

212

56 000

(2007-09)

Region MMR

Life time risk

% share of female Popln.

% to total maternal

deaths

EAG states 308

1.1% 48.0 61.6

Southern states

127

0.3% 21.0 11.4

Other states

149

0.4% 31.0 27.0

India 212

0.6% 100 100

LEVELS OF MMRATIO BY REGIONS, 2007-09

100

150

200

250

300

350

400

450

500

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

MM

RA

TIO

Years

Maternal Mortality Ratio (MMR) in India - SRS: Trends based on Log-Linear model (1997-2015)

• TFR for the country has come down to 2.5 from 2.6 in 2009.

• Bihar has reported the highest TFR (3.7) while replacement level TFR, viz 2.1, has been attained by Tamil Nadu(1.7), Kerala(1.8), Andhra Pradesh (1.8), Himachal Pradesh (1.8), Punjab (1.8), West Bengal (1.8) , Delhi (1.9), Maharashtra (1.9), Jammu & Kashmir(2.0) & Karnataka (2.0).

• At present, a rural woman (having a TFR of 2.8) at the National level would have about one child more than an urban woman (having a TFR of 1.9), on average

Total Fertility Rate (TFR) estimates 2010: Highlights

• TFR for the country declined by 1.3 points (down by more than a child), rural TFR also by 1.3 points and urban TFR by 0.9 point over last 20 years

• Another 10-12 years to achieve the replacement level of 2.1 at the current fertility rates

3.8 3.5

3.2

2.9

2.5

4.1

3.9

3.5

3.2

2.8 2.8

2.6

2.3

2.1

1.9

1.5

2.0

2.5

3.0

3.5

4.0

4.5

1990 1995 2000 2005 2010Total Rural Urban

Total Fertility Rate (TFR) BY RESIDENCE, 1990-2010

ANNUAL HEALTH SURVEY- A NEW INITIATIVE

“ To yield a comprehensive, representative and reliable dataset on core vital indicators including composite ones like IMR, MMR and TFR along with their co-variates (process and outcome indicators) at the district level and map changes therein on an annual basis”

OBJECTIVE OF AHS

Coverage : Annual Health Survey

Odisha

Chhattisgarh

JharkhandMadhya P radesh

Bihar

AssamRajasthan

Uttar Pradesh

Uttarakhand

o AHS States constitute: • 48 percent of country’s Population • 59 percent of Births • 70 percent of Infant Deaths • 75 percent of Under 5 Deaths • 62 percent of Maternal Deaths

o Enable direct monitoring of UN Millennium Development Goals on Child Mortality and Maternal Health at the district(s) level.

o Help in identifying high focus districts meriting

special attention in view of stark inter-district variations in these States.

WHY AHS ?

• Panel Survey on the pattern of SRS

• Coverage- All the 284 districts of 8 EAG States and Assam.

• Sample Size- IMR as the decisive indicator with 10%RSE.

• Sample Units- 20,694 statistically selected sample unit

(Census Enumeration Blocks in urban areas and Villages or a

part thereof in rural areas)

• Sample Population- About 20.1 million

• Sample Households - 4.1 million households.

• Sample Units per district- 73.

• Sample Population per district - About 71 thousand.

• Sample households per district - About 14.5 thousand.

The Largest Sample Survey in the World

KEY FEATURES

• In all, 161 indicators are available from AHS baseline: Fertility- 13 Sex Ratio- 3 Marriage- 5 Mortality- 7 Mother & Child Care- 63

Ante Natal Care: 11 Delivery Care: 8 Post Natal Care: 5 Janani Suraksha Yojana (JSY): 3 Immunization: 8 Vitamin A & Iron Supplements: 2 Birth Weight: 2 Childhood Disease: 6 Birth Registration: 2 Breastfeeding & Supplementation: 12 Awareness in Mothers: 4

Abortion- 6 Family Planning Practices- 15 Disability- 1 Morbidity- 19 Personal Habits:adults-4 Housing & HH Characteristics- 13 Others- 12

INDICATORS UNDER AHS

State Total no. of

districts State Value

Districts with minimum IMR

Districts with maximum IMR

Range

UTTARAKHAND 13 43 Rudraprayag (19) Haridwar (72) 53

RAJASTHAN 32 60 Kota (36) Jalor (79) 43

UTTAR PRADESH 70 71 Kanpur Nagar (36) Shrawasti (103) 67

BIHAR 37 55 Patna (39) Madhepura (71) 32

ASSAM 23 60 Dhemaji (44) Kokrajhar (76) 32

JHARKHAND 18 41 Purbi Singhbum (26) Godda (64) 38

ODHISSA 30 62 Baleshwar (49) Balangir (100) 51

CHHATTISGARH 16 53 Durg (43) Raigarh (65) 22

MADHYA PRADESH 45 67 Indore (40) Panna (93) 53

IMR across 284 districts ranges between 19 (Rudraprayag; Uttarakhand) & 103 (Shrawasti, UP) – a variability of 5 times!

6 districts viz. Purbi Singhbhum & Dhanbad (Jharkhand); Chamoli, Rudraprayag, Pithoragarh & Almora (Uttarakhand) have already achieved MDG-4 National target of 28 by 2015

INFANT MORTALITY RATE

Oriss a

Chhattisgarh

Jharkhand

M adhya P radesh

Bihar

AssamRajasthan

Uttar P radesh

Uttarakhand

Infant M ortality Rate

Top 100 D istricts in AHS States

NNMR across 284 districts ranges between 11 (Rudraprayag; Uttarakhand) & 75 (Balangir, Orissa) – a variability of 7 times!

Out of every 10 infant deaths, 6-7 pertains to neonates

NNMR in rural areas of districts is significantly higher than that in urban areas

State Total no. of

districts State Value

Districts with minimum NNMR

Districts with maximum NNMR

Range

UTTARAKHAND 13 30 Rudraprayag (11) Haridwar (50) 39

RAJASTHAN 32 40 Kota (25) Jalor (58) 33

UTTAR PRADESH 70 50 Kanpur Nagar (24) Shrawasti (73) 49

BIHAR 37 35 Patna (22) Madhepura (49) 27

ASSAM 23 39 Dhemaji (27) Dhubri (50) 23

JHARKHAND 18 26 Purbi Singhbum (17) Lohardaga (41) 24

ODISHA 30 40 Anugul (31) Balangir (75) 44

CHHATTISGARH 16 35 Durg (29) Raigarh (45) 16

MADHYA PRADESH 45 44 Indore (25) Panna (66) 41

NEO NATAL MORTALITY RATE

State Total no. of

districts State Value

Districts with minimum U5MR

Districts with maximum U5MR

Range

UTTARAKHAND 13 53 Pithoragarh (24) Haridwar (94) 70

RAJASTHAN 32 79 Kota (45) Jalor (99)

Banswara (99) 54

UTTAR PRADESH 70 94 Kanpur Nagar (52) Shrawasti (142) 90

BIHAR 37 77 Patna (53) Sitamarhi (106) 53

ASSAM 23 78 Dhemaji (52) Kokrajhar (103) 51

JHARKHAND 18 59 Purbi Singhbum (36) Godda (93) 57

ORISSA 30 82 Balasore (58)

Jharsuguda (58) Kandhamal (145) 87

CHHATTISGARH 16 70 Durg (52) Surguja (103) 51

MADHYA PRADESH 45 89 Indore (51) Panna (140) 89

U5MR ranges between 24 (Pithoragarh, Uttarakhand) & 145 (Kandhamal, Orissa) - a variability of 7 times!

7 districts viz. Pithoragarh, Almora, Rudraprayag, Chamoli, Nainital & Bagheswar (Uttarakhand) and Purbhi Singhbum (Jharkhand) have already achieved MDG National level target of 42

U5MR MORTALITY RATE

MMR ranges between 183 (Kumaon HQ, Uttarakhand) & 451(Faizabad Mandal, UP)

MMR for Uttarakhand along with its two divisions is lower than the

National Average (212)

State Total no. of

Admin. Division State Value

Admin. Division with minimum MMR

Admin. Division with maximum MMR

Range

UTTARAKHAND 2 188 Kumaon HQ (183) Garhwal HQ (190) 7

RAJASTHAN 7 331 Bharatpur (292) Udaipur (364) 72

UTTAR PRADESH 18 345 Jhansi Mandal (241) Faizabad Mandal (451) 210

BIHAR 9 305 Patna (258) Purnia (377) 119

ASSAM 4 381 Hills & Barak Valley

(342) Upper Assam (430) 88

JHARKHAND 5 278 Uttari Chota Nagpur

(208) Santal Paragana (325) 117

ODISHA 3 277 Northern (253) Southern (311) 58

CHHATTISGARH 4 275 Raipur (243) Bastar (312) 69

MADHYA PRADESH 10 310 Gwalior (262) Shahdol (435) 173

MATERNAL MORTALITY RATIO

Oriss a

Chhattisgarh

Jharkhand

M adhya Pradesh

Bihar

Assam

Rajasthan

Uttar P radesh

Uttarakhand

M aterna l M ortali ty Ra tio

Top 2 5 Ad m in istrative D ivisions in

A H S S tates

M M R

Top 25

Ad m in is tra tive D iv is ions

Total Fertility Rate (TFR)

State State value Minimum Maximum Range

Assam 2.6 Kamrup (2) Hailakandi (4.2) 2.2

Bihar 3.7 Patna (2.8) Sheohar (4.7) 1.9

Jharkhand 3.1 Purbi Singhbhum (2.4) Lohardagga (4) 1.6

Madhya Pradesh 3.1 Indore (2.2) Shivpuri (4.5) 2.3

Chhattisgarh 2.9 Koriya (2.4) Kawardha (3.7) 1.3

Odisha 2.3 Jharsuguda (2) Boudh (3.7) 1.7

Rajasthan 3.2 Kota (2.6) Barmer (4.7) 2.1

Uttar Pradesh 3.6 Kanpur Nagar (2.3) Shrawasti (5.9) 3.6

Uttarakhand 2.3 Pithoragarh (1.7) Haridwar (3.1) 1.4

Across 284 districts in 9 AHS States, it ranges from 1.7 in Pitthoragarh (Uttarakhand) to 5.9 in Shrawasti (UP)- a variability of more than 4 children.

20 districts have already achieved the replacement level of 2.1. • 164 districts have recorded TFR of 3.1 and above, the National

level TFR of 2001 (SRS).

Total Fertility Rate (TFR)

Top 100 districts in order of IMR constitute about 50 percent of total Infant Deaths across 9 States

Top 25 Administrative Divisions (comprising 104 districts) in order of MMR constitute 41 percent of the total Maternal Deaths

Top 100 districts in order of U5MR account for 63 percent of total child deaths.

57 districts are in common – Hot Spots

Replacement level of TFR 2.1 has been achieved in only 20 out of 284 AHS districts.

A Component of Clinical-Anthropometric & Bio-chemical (CAB) Test on a sub-sample basis is scheduled to be introduced in October.

KEY FINDINGS

No survey can be an effective and sustainable substitute for Civil Registration System

Thank You

Registrar General and Census Commissioner, India,

2 A Mansingh Road, New Delhi 110011, India

Phone: +91-11-24105383

Fax: +91-11-23383145

E mail: rgi.rgi@nic.in Website: http://www.censusindia.gov.in