In India, even before the COVID-19 pandemic , around 85% of all deaths were registered and only one-fourth of the registered deaths were medically certified for the causes of death. There have been wide variations among States and within them, in rural and urban areas. Understanding the causes of death is essential for health sector planning and optimal allocation of health resources. In the absence of robust data on the causes of death , governments rely on estimates.
Reporting COVID-19 deaths
The World Health Organization has estimated that world over, COVID-19 deaths could be two-three times the officially reported numbers. Public health experts, disease modellers, and research institutes which specialise in morbidity and mortality data have estimated that COVID-19 deaths in India could be in the range of three to 14 times the officially reported number of deaths.
As per ground reports, there has been under-reporting of COVID-19 deaths during the second wave of infections in India. In April and May 2021, crematorium and burial grounds had long queues, dead bodies were floating in rivers, more cremations were being done following the COVID-19 protocols than the officially reported number of deaths, and everyone had a few people in their social circle who had succumbed to COVID-19. All of these have been captured in media reports from various settings, including major cities and a number of States. Each of these cities and States has reported excess deaths (comparing two similar periods in different years) that are twice to even 30-40 times higher than the officially reported COVID-19 numbers.
Rural India is known to have a weak death registration system; however, there is corroborative evidence of excess deaths. At an existing death rate of seven per 1,000 people, an average village of 1,000 people should report around one death every two months. But most Indian villages have experienced deaths at a far higher rate in the two months of the second COVID-19 wave.
The Union and State governments have always been quick to deny estimates. Their core argument has been that COVID-19 deaths cannot be hidden. However, the biggest counter to this position has come from the reconciliation of COVID-19 deaths in Bihar and Maharashtra. Following reviews and audits, these States showed a nearly 75% increase in COVID-19 deaths over the officially reported deaths for the specified periods. The reconciliation from Bihar and Maharashtra was attributed to under-reporting in private hospitals, in home isolation, in transit to the hospitals/facilities and those who died with post-COVID-19 complications. In some of the districts, the revision resulted in the increase being twice or thrice the number of reported deaths. Therefore, it is logical to conclude that if and when other States initiate similar exercises, they are likely to report an upward shift in COVID-19 deaths.
In fact, the majority of the current analyses of excess deaths has come from urban settings and large municipal corporations, known for a relatively better functioning death registration system. The challenges in death reporting in rural areas are very different and far bigger. During the second wave, access to COVID-19 testing services and treatment facilities was limited in rural India. Pandemic-related restrictions, lack of transport and the health-seeking behaviour of citizens indicate that many people from the villages did not come in contact with the formal health system, which is concentrated in urban settings. Very few rural health facilities were providing services for COVID-19 care. Many people were admitted in the healthcare facilities without a RT-PCR test, and on the basis of clinical symptoms. As many ground reports have shown, deaths in these sub-groups did not make it to officially reported COVID-19 deaths.
One of the core objectives of the pandemic response is to reduce mortality. Therefore, COVID-19 deaths are a good surrogate indicator of the health system’s performance at the State and district levels. This is a more focused indicator of the response of the health system compared to process-oriented indicators such as daily tests conducted or dedicated COVID-19 beds added. If realistic estimates of COVID-19 deaths by city, rural settings, districts and States are known, a more targeted response could be mounted to the pandemic. The death estimates could be very useful to plan for the next wave of the pandemic (in the short term) and to strengthen the Indian health care system (in the long run).
Refining estimates
There are at least four approaches which can help us refine the estimates: death audits; excess death analysis; death surveys followed by verbal autopsies; and decadal Census, which is due in India.
First, every State should get death audits done to correctly classify all the deaths that occurred during the pandemic. The audits should focus on all the health facilities, in the public and private sector, as well as deaths in homes. The process of death audits needs to be institutionalised. The experiences of Bihar and Maharashtra show that this can be done quickly.
Second, the excess deaths in the pandemic period should be analysed more systematically. For urban settings and those States which have a relatively high death registration, such analysis can be done in a short period of time.
Third, rural areas and smaller towns require additional data collection. The death registers at the village level can be utilised and panchayats can provide this data in real-time, which can be collated by the administration. The sample registration system teams functioning under the Registrar General and Census Commissioner in India and the booth-level officers used in elections can be mobilised to collect additional information on deaths reported in April and May 2021. This can help the government in getting more realistic death estimates in the next few months. The Jharkhand government completed one such survey, focused exclusively on rural areas, which found 43% excess deaths than the comparable period before the pandemic. The State surveyed two-third of its population with the help of the existing workforce, in 10 days. Such surveys should be planned by all States, followed by verbal autopsy, to assign the causes of deaths.
Fourth, there is an urgent need to initiate the decadal Census in India. The U.S. and China conducted their census in 2020 during the pandemic. India should urgently plan for the Census, which would provide useful data for all sectors. Inter-censal growth will provide an important insight into the excess mortality.
The political leadership and health policymakers seem to be taking solace in the fact that India has not yet reported the highest number of COVID-19 deaths in the world. However, there is bigger merit in developing realistic COVID-19 death estimates, which could be more helpful in policy formulation, planning, resource allocation and health system strengthening. Therefore, the governments at all levels (Union, States and districts) should work to come up with the estimated number of COVID-19 deaths. That kind of granular data on deaths along with other health data will help India fight the pandemic and plan for the post-pandemic period more effectively.
Chandrakant Lahariya, a physician-epidemiologist, is a public policy and health systems expert and co-author of Till We Win: India’s Fight Against The COVID-19 Pandemic
