From 1992-2018, the percentage of medically certified deaths to total registered deaths fluctuated between 12 and 22%
The percentage of medically certified deaths vis-à-vis total registered deaths fluctuated in 25 years between 1992 and 2018. The annual hospitalisation rate per 1,000 patients was 16.7 in 1995-96, which increased to 37 by 2014.
These are among the many takeaways of the study based on the information by Medical Certification of Cause of Death (2018) received from 35 states and Union territories based on the International Classification of Diseases (ICD), 1993.
The focus of the study was to assess the percentage of medically certified deaths to total registered deaths in India considering three major aspects:
In India, state governments have the authority to enforce issuing of Medical Certification of Cause of Death (MCCD) by the medical practitioner who attended to the deceased at the time of death. This scheme applies only to certain areas and hospital facilities.
The scheme is vital from the viewpoint of generating reliable data on cause-specific mortality statistics of the population.
From 1992-2018, the percentage of medically certified deaths to total registered deaths fluctuated between 12 and 22 per cent. In 1992, the total number of registered deaths was 2,305,398, out of which only 374,839 deaths (13.7 per cent) were medically certified.
In 2006, a slight change of trend was witnessed, when out of the total registered deaths (4,327,664), the number of medically registered deaths rose to 720,047.
From 2006-2010, a gradual increase in medically certified deaths was seen. In 2010, 970,896 medically certified deaths (20.2 per cent) out of total registered deaths (4,813,552) were recorded.
From 2010-2014, no significant change was observed in the percentage of medically certified deaths.
From 2014-2018, the percentage of medically certified deaths was between 19 and 22 per cent. In 2018, out of 6,911,197 medically reported deaths, 1,456,023 (21.1 per cent) were medically certified.
In India, the annual hospitalisation rate per 1000 was 16.7 in 1995-96, which went up to 37 by 2014. One of the possible reasons is the National Rural Health Mission launched in 2005, which increased the ease in the rural population in getting medical assistance. Substantial increase in the private sector of healthcare facilities also increased the hospitalisation rate with every passing year.
From 2006 to 2016, the inpatient expenditure increased to 300 per cent, mainly as a result of supply-induced demand. A huge chunk of India’s population is not covered under any health insurance effectively, although the ‘publicly funded health insurance schemes’ (PFHIs) claim to cover 300 million population.
Several reports, however, have stated that PFHIs cover only 12.8 per cent of the population, which is concentrated mainly in upper quintiles and urban areas. Health insurances do not cover all the amount of the expenditure. Hence, the rate of hospitalisation has not gone up effectively, which is ultimately leading to less medically reported deaths.
Among states, Goa had the highest percentage of medically certified deaths (nearly 100 per cent) followed by Mizoram and Manipur (each above 50 per cent).
Among UTs, Lakshadweep has the highest number of medically certified deaths (94.9 per cent) followed by Daman & Diu (90.8 per cent) and Puducherry (74 per cent). All the other UTs are among the administrative units with a high percentage of medically certified deaths (above 50 per cent in each).
Jharkhand had the lowest percentage of medically certified deaths (4.6 per cent) followed by Uttar Pradesh (5.1 per cent), Madhya Pradesh (10.5 per cent), Odisha (11.1 per cent), and Kerala (11.9 per cent).
The hospitalisation rate in the less developed states (Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Uttar Pradesh, Uttaranchal, Odisha, Rajasthan, Assam, Arunachal Pradesh, Manipur, Mizoram, Meghalaya, Nagaland, Sikkim, Tripura, Himachal Pradesh, and Jammu and Kashmir) in 2014 was 26.1 per 1,000; it was 48.6 per 1,000 for developed states (Goa, Gujarat, Haryana, Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu, Telangana, Andhra Pradesh, and West Bengal).
Fewer hospitalisation rates in 18 states of India were a major cause behind lower percentages of medically reported deaths.
A contrasting picture was put forward by Kerala; it has a good health infrastructure, and yet only 11.9 per cent of medically certified deaths were recorded there. One major reason was the number of medical institutions covered under MCCD in the state.
According to MCCD report 2018, out of 2,519 medical institutions having in-patient facilities in Kerala, only 150 were covered under MCCD. So, even if the hospitalisation rate was comparatively better in Kerala, the provision of MCCD was not effectively implemented.
Bihar, the third-largest state in India (population-wise), has only 683 medical institutions with in-patient facilities, out of which only 42 are covered under MCCD. This was among the reason that most deaths in Bihar were not medically reported.
How states fare
Goa has topped the charts since 2016: All reported deaths have been medically certified deaths.
Lakshadweep showed a significant increase of about 11.9 per cent in MMCD: From 83.5 per cent in 2016 to 95.4 per cent in 2017. It was 94.9 per cent in 2018.
Similarly, Daman and Diu also reported an increase in MCCD of 8.2 per cent from 2016 (78.8 per cent) to 2017 (87 per cent). The percentage MCCD went up to 90.8 per cent in 2018.
Puducherry and Chandigarh witnessed a downfall in the percentage MCCD from 2016 to 2017 of 9 per cent and 3.5 per cent respectively.
Although by 2018, Puducherry increased its percentage MCCD gradually to 74 per cent whereas a significant increase of 27.3 per cent from 2017 (44.3 per cent) to 2018 (71.8 per cent) was witnessed in percentage MCCD in Chandigarh.
Nagaland too recorded a significant increase of 19.5 per cent from 2016 (9.2 per cent) to 2018 (28.7 per cent).
Among the states with the least percentage of MCCD, Odisha and Uttar Pradesh showed a drop of about 1.8 per cent and 0.6 per cent respectively from 2016 to 2018. A significant increment in percentage MCCD in Uttar Pradesh was recorded in 2017 (8.6 per cent).
States and UTs like Lakshadweep, Daman and Diu, Chandigarh, Mizoram, Telangana, Maharashtra, Nagaland have recorded more than a 10 per cent increase in MCCD since 2016.
Dadar & Nagar Haveli, Karnataka, Tripura, Andhra Pradesh, Rajasthan, Assam, Odisha and Uttar Pradesh have recorded a downfall in percentage MCCD since 2016 ranging between 22.1 per cent (Dadra and Nagar Haveli) to 0.6 per cent (Rajasthan and Uttar Pradesh).
As many as 18 states in India have less than 30 per cent deaths covered under MCCD out of the total deaths medically reported. Among these, eight are among the top 10 highly populated states, according to Census 2011.
Effective implementation needed
The Medical Certification of Cause of Death scheme, even after being a vital source of population data on health, has not been implemented effectively in the country. Not even a fourth of the total medically reported deaths are certified.
A possible reason is that not all states have enough medical institutions with in-patient facilities proportional to its population. Also in some states, out of these medical institutions, only a few are covered under MCCD.
Hence, the rate of increase in percentage MCCD is quite low for the country as a whole as it has increased only 2.1 per cent from 2016 (19 per cent) to 2018 (21.1 per cent).
The northern and eastern states of India have a very low percentage of MCCD compared to the rest of the country, with an exception of Kerala among southern states. A huge population lives in states where the MCCD percentage is below 30 per cent. A better implementation of the MCCD scheme is needed.
All UTs have a higher percentage of MCCD. Out of the seven UTs, four (Andaman & Nicobar Islands, Dadra and Nagar Haveli, Daman & Diu, and Lakshadweep) have 100 per cent coverage of all medical institutions under MCCD.
Puducherry’s 65.2 per cent medical institutions are covered under MCCD whereas 37.1 per cent of medical institutions are covered under MCCD in Chandigarh. As many as 900 medical institutions report MCCD data in Delhi.
The government needs to shift its role from a purchaser of care to service providers effectively enough to financially secure its health care seekers. There is also a need for periodic surveys that can collect data for better guidance towards strategising financial protection of citizens of the country.
Views expressed are the author's own and don't necessarily reflect those of Down To Earth
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