The study identifies three main themes which were found to be the key barriers in managing high performance death registration at the local level: administrative challenges, technical capacities and societal contexts. Seven sub-themes were identified under main themes. In Table 2, the profiles of KII and FGD participants are described.
The first barrier: administrative challenges
Lack of enforcement of mandatory death registration
Both document review and KII respondents indicated that there is no specific law enforcing mandatory death registration in Myanmar, though there are some related laws that are used to manage death registration, such as The City of Yangon Municipal Act, 1922; The Myanmar Village Headman Manual, 1948; The Development Affairs Act, 1993 and the Ward and Village Tract Administration Law, 2012 [3]. The Ward and Village Tract Administration Law (2012) is the most updated one, where every birth and death has to be reported to Ward Administrator (WA) or Village Tract Administrator (VTA) within three days (or 24 h if the death occurs due to infectious disease). Non-compliance should result in imprisonment of not exceeding seven days by the relevant court or a fine not exceeding fifty thousand kyats (approximately $38) [10]. However, according to Key Informant Interviews with local administrators, enforcement for non-compliance is rare, especially in rural areas.
WA and VTA whom referred to by the Ward and Village Track Administration Law are working under the Township General Administrative Office (TGAO) which is under General Administrative Department (GAD), Ministry of Home Affairs. The TGAO performs various other functions of government including recording and reporting of births and deaths to GAD. WA and VTA play roles in administration at the ward and village tract level. WA and VTA are supervised by Township Administrator and Deputy Township Administrator; supported and assisted by clerks and community leaders who are volunteers. In every ward and village tract, there are many community leaders who are assigned to every 10 households, 100 households, or a defined territory. They help WA or WTA in performing their functions by directly contacting with the households and communities [11].
The regulations related to vital registration functions of WA or the VTA are: 1) the WA and VTA have to provide instructions to the households for registering births and deaths within 3 days of occurrence of the event; 2) they have to supervise recording births and deaths and informing to health centers [10].
Although the law instructed to report every birth and death to WA or VTA, in the Vital Registration Training Manual, it was stated that, for vital events occurred in the community, death records (Form 201) and death register (Form 202) have to be completed by the Midwives (MW) or Public Health Assistant 2 (PHS 2). For events occurred at hospitals, the registered doctors has to complete the records including “Medical certificates of cause-of-death form”. Registering and reporting vital events to CSO are performed by health staff and supervised by the in charge of the health facility [3, 12].
Limited issuance of death certificates
District or Township Medical Officer has to take responsibilities to sign and issue Death Certificate (Form 203) and Burial Certificate (Form 204) to family members of the deceased upon request [3, 12]. The township medical officer (TMO) from KII explained that issuing death (Form 203) or burial certificates (Form 204) to the deceased’s family was not a routine procedure in the study township. It means, in general, people in the study areas do not request the certificates because of its limited usefulness. A death certificate is required to apply for a family pension if the deceased is a government official, to claim an inheritance, or to gain a burial certificate as required in some areas.
As confirmed by findings from FGDs and KIIs, a death or burial certificate is not necessarily required in rural areas. For cremation or burial in urban areas of the less urbanized township, a burial certificate from the township office of the General Administrative Department (GAD) or township Developmental Affairs Office (DAO), but not from the health center, is required. On the other hand, in the more urbanized township, a burial certificate issued by the district hospital was needed for burial or cremation.
No formal mandatory notification of death events by households
According to FGDs and KIIs with health staff, family members in both urban and rural areas did not report to the health center when a person died in their households. Instead, local health staff, specifically MWs, had to collect information and complete them in death record (Form 201) and death register (Form 202) by themselves. To perform their assigned function of recording and registering deaths occurred in their geographical catchment areas, MWs searched for the information of death events through various sources (Fig. 3). For example, through health volunteers who reported death events to MWs when MWs came for provisions for outreach immunization or antenatal care; or through local social practices in which the deceased’s family invited the community to the funeral using a community loud speaker, or through posting a board on the street; or through local administrators such as WA, VTA, 10-household or 100-household leaders.
“If someone dies in the village, the family invited local residents to the religious practices for the funeral using a loud speaker. So, everyone knows there was a death in certain household. Then, we go there to record the event.” (MW from RHC)
However, if the deceased is a government staff, the family members reported death to the health center because they need a death certificate for applying family pension.
On the other hand, when a death occurred in the household, family members usually informed the local administrator. According to the FGD with community members from rural areas, even if the family members could not inform the administrator by themselves, the village volunteers reported deaths on behalf of the deceased’s family.
The villagers explained that every village had their own cemetery but it is not necessary to present an official approval letter for burial or cremation. They informed administrators and got a “verbal approval” from local administrator to cremate or bury.
In addition, every village in the study area had a volunteer group which was mostly led by local administrators, and the group provided an assistance to the funeral home in many ways. So, by informing the village leaders, the deceased’s family automatically received aids from the volunteer group in arranging funeral processes.
In contrast, participants from urban areas of a more urbanized township said they had to inform the local administrator because they needed approval letters from the administrative office and the municipal office for cremation or burial. However, such practice was not required in urban areas of the less urbanized township.
It seems information of household deaths reached to the local administrators even though there was no an established system, especially in rural areas. Similarly, the means the MW obtained information of death events from local administrators was not systematic which can seriously affect the completeness of death registration.
“I requested the village leader to tell me if there is a birth or a death in the village as I had to make a report around 20th of every month.” (MW from RHC)
In some areas, local administrators or volunteers informed voluntarily to the MWs about death events occurred in the area. In some areas, the MWs had to contact them by phone to complete the forms before they prepare a report.
“In my area, there are hundred-household leaders. I save their phone numbers so that I can contact them if necessary. At the end of each month, I call and ask them who died in their sections, why, how old the person was and other required information.” (MW from MCH)
All information from FGDs and KIIs confirms there is no formal system of death reporting to health centers from households. Collection of these data by other means can result in incompleteness of death registration.
The second barrier: technical capacities
The absence of proper and regular on-the-job trainings
Midwives, the front line health workers of vital registration, did not receive proper and regular on-the-job trainings on vital registration. Most of them had attended a 45-min lecture on how to fill out the birth and death records as a part of their pre-employment training program. There were few healthcare providers, TMO, LHV and MWs, who had received a comprehensive training for vital registration more than ten years ago. With the absence of well-designed training programs, most of healthcare providers did not have adequate knowledge of rules, regulations and procedures related to death registration which resulted in inadequacy and low quality of recording vital events. Not many healthcare providers knew the registration of vital events was based on the place that the vital events took place, i.e. place of occurrence. In addition, almost all healthcare providers had not seen vital registration manuals published by the CSO in their office.
Ineffective COD certification practices for deaths in the communities
In the study townships, the responsible MW had to assign a possible COD on the death record for deaths that occurred in geographical catchment areas under her responsibility. The MWs usually obtained the information from local administrators or family members who witnessed the mortality event. All MWs agreed that it was challenging for them to get the definitive COD, and most sources of information were not well-grounded.
“It’s hard to get a correct cause of death information if the person dies at home. Usually, we record the cause as provided by the lay informant.” (HA from RHC)
Some MWs spelt out that they sometimes filled in the name of a disease which they felt to be common in that age group when no one could provide the reliable information.
“If we don’t know, just name it as hypertension or diabetes if he or she was old. If he was a heavy drinker, I will name it as liver disease.” (MW from MCH)
However, if the person died after being discharged from the hospital, it was straightforward for the MWs to acquire valid causes of death from medical records or from laboratory or radiological results.
The absence of routine data plausibility checks at the local level
Findings from FGDs and KIIs confirmed that the consistency of vital information (i.e. total number of deaths) recorded in the area between the health sector and administrative office was verified on the last week of each month. Inconsistencies were rectified based on local administrative office data, which was regarded as a more reliable source of death information.
“Every month, the staff from our department, administrative office and immigration office meets together and check the consistency of data, such as how many deaths are recorded in the health department, how many deaths in the administrative office data and the number of population increased or decreased in the immigration office.” (TMO from the hospital)
Apart from that, there were no established procedures or defined parameters for consistency and plausibility checks for the submitted death registration data. There was also no specific supervision or monitoring of death registration functions, procedures and quality of data.
The third barrier: societal contexts
Poor community awareness and participation in death reporting and registration
Most community members who participated in the FGDs did not know about the requirement for registering deaths such as when, where, how and why they should report and have them registered. Respondents from rural households reported that they had not registered deaths at all. MWs from FGDs also reported that the public was not aware of requirements for death registration, especially in rural areas. Moreover, they said, some family members did not want to provide information to health officials about the deceased. Many health care providers, MOs and MWs, regarded that people did not report deaths to the health center because of the more limited utility of death certificates compared to birth certificates.
“Concerning birth registration, we have no difficulties because it has its own utility. But there is no usefulness of a death certificate. Even a burial certificate is not required for cremation. In such a situation, people might question why they need to register, what they can do with a death certificate or where it can be used. They may consider that after the person has already died, why it is necessary.” (TMO from the hospital)
In urban areas, there were some people who had heard about registering deaths and its usefulness for applying for a family survivor pension. In the more urbanized township, where the certificate issued from the health center must be presented for burial or cremation, people reported deaths to the health center.