Mortality data, especially concerning deaths by cause, are critical for understanding the burden of disease, planning and monitoring of interventions aimed at reducing morbidity and mortality, as well as monitoring the Sustainable Development Goals for health (goal 3). In sub-Saharan Africa and most limited resource settings where burdens of diseases are high, there is a chronic lack of accurate and reliable data on mortality and causes of death. In these settings, complete diagnostic autopsy is only available in large hospitals and is unaffordable to most people. In addition, most deaths occur at the community level, and for facility deaths, physician medical certification of cause of death using medical information is not systematically completed. Available recent mortality and cause-of-death statistics are mostly based on modeling or periodic national surveys. Although they represent important tools, the uncertainty or long time intervals associated with their estimates challenge their use for precise or timely policy and program planning. Progressive efforts undertaken by low- and middle-income countries (LMICs) to revamp and expand their civil registration and vital statistics (CRVS) systems are commendable and timely. However, the time and resource needs—in terms of infrastructure, technology, equipment, human resources, and demand creation—to reach the entire population with a fully functional CRVS system are enormous and deprioritized in favor of more pressing demands in health care. The recent COVID-19 pandemic and emergence of epidemics across LMICs unveiled the vulnerabilities and challenges associated with the lack of or weak mortality data systems that can support planning, monitoring, and decision-making in these countries.
In this context, building sustainable and resilient mortality surveillance systems that provide high-quality and timely mortality data represents a priority in Africa, as recently expressed in a newly developed continental framework for strengthening mortality surveillance in Africa by the Africa CDC.1
The situation in Mozambique is no different from that in other LMICs, where facility-level data on mortality face similar challenges. However, Mozambique launched a major initiative in 2017 to address these challenges, through the development and implementation of a national sample vital statistics system that can routinely produce national and subnational mortality and causes of death data. The initiative, named Countrywide Mortality Surveillance for Action (COMSA), was implemented jointly by the two major national institutions that are responsible for population and health data collection, the National Institute of Statistics (Instituto Nacional de Estatística [INE]) and the National Institute of Health (Instituto Nacional de Saúde [INS]). Technical support was provided by the Johns Hopkins University, and financial support came from the Bill & Melinda Gates Foundation. Before the launch of COMSA in 2017, the country relied on Demographic and Health Surveys, conducted in 1997, 2003, and 2011; a one-time post-census mortality and cause of death survey conducted in 2007; and United Nations modeled statistics for mortality data.
Countrywide Mortality Surveillance for Action is a community-based surveillance system with national and provincial representation, providing a unique opportunity for Mozambique to have accurate and continuous data on mortality, causes of death, and social determinants of death across all age groups. The system targeted 700 randomly selected geographic clusters and trained community workers to report data on pregnancies, pregnancy outcomes, and deaths using mobile phones. More than 60 field data assistants have been trained and are based at the provincial level to supervise community workers and follow up with families of the deceased to collect verbal autopsies. At the central level in Maputo, technical and administrative teams from the INS and the INE monitor the system electronically and conduct frequent visits to the provinces and communities for supervision, monitoring, and capacity strengthening. A robust digital and Web-based system is in place to capture data from the communities and transfer it in real time to the provincial and central levels, where they are reviewed and analyzed. The system allows interrogating the data in real time, analyses to answer relevant questions, data visualizations, and dissemination of the data through a Web portal. Thus, the COMSA system generates all-cause and cause-specific data for use and has established continuous and capacitated teams from communities to the central level for the continuous production of such data. In Mozambique, COMSA is being integrated into the health management information system using the District Health Information Software 2 platform to complement facility level data with community-based data at national and provincial levels. Discussion is also underway to link the system to the national CRVS system to ensure that data collected serves to reinforce the expansion and strengthening of the CRVS system.
Africa Centres for Disease Control and Prevention , 2022. Strengthening Mortality Surveillance in Africa: Africa CDC Launches Continental Framework Document to Support Member States. Addis Ababa, Ethiopia: African Union. Available at: https://africacdc.org/news-item/strengthening-mortality-surveillance-in-africa-africa-cdc-launches-continental-framework-document-to-support-member-states/. Accessed December 14, 2022.
Jiwani S , Mavie VA , Williams E , Kante AM , Amouzou A , 2023. Implementing the Countrywide Mortality Surveillance in action in Mozambique: how much did it cost? Am J Trop Med Hyg 108: 40–46.