With Only 2 Out of Every 100 Deaths Recorded in Lagos State, Nigeria, Government Health Programs Are Flying Blind, but Advocates Are Working Toward Rapid Change

Why is death registration a global issue?

Keshinro: Death notification and registration is recognized by the United Nations as an essential recording of a person’s vital event that should be continuous, permanent, compulsory and universal. Without data that accurately captures life events—such as birth and death—public health, population planning and development policies will suffer. Civil registration and vital statistics (CRVS), which includes death data, is central to monitoring several U.N. Sustainable Development Goals. The goals include a target for universal birth registration and an indicator for 80% death registration by 2030.

Why is death registration essential for country planning?

Orah: Death registration helps to answer essential questions needed for CRVS systems, such as:

• the cause of death, which is important for public health policy and decision-making;
• where the death occurred, which may help identify disease outbreaks or other concerns in an area;
• the legal identity of the deceased.

Aggregate death records can also help determine how many people died in a particular time frame, which affects the census or enumeration process.

Is death registration obligatory in Nigeria?

As in many other U.N. member countries, birth and death registration are obligatory in Nigeria. Unfortunately, unlike births, which tend to be happy events, deaths are mostly sad occurrences and the people involved usually focus on religious and cultural events, such as funeral rites. Family members are less likely to be focused on the obligatory notification of death to the statutory governmental organization in Nigeria, the National Population Commission.

What is your office’s role in registering deaths for Lagos State in Nigeria?

Keshinro: In Nigeria, the Police Force Pathologist Office is involved in the reporting of deaths and in ensuring the quality of death data through the medicolegal death investigation system. It is our office’s duty to notify the National Population Commission when a death is reported to the police. This is why our team at the Police Force Pathologist Office has become more involved with CRVS processes in Lagos State, including death notification, certification, and the issuance of a medical cause of death certificate by medical personnel. When investigating these issues alongside the National Population Commission, we discovered that reporting and registration of death in Lagos State was abysmally low.

Can you explain more about the ins and outs of the project to increase death notification and registration in Lagos State?

Keshinro: Since its inception in March 2022, this grant from the Data for Health Global Grants Program has enabled us to focus on improving mortality statistics at the subnational level in Nigeria. We originally aimed to increase death notification and registration by 75% in Lagos State, which is home to approximately 13% of Nigeria’s population. With a 173% increase, we have far exceeded this goal. Our Global Grants project is the first program to address death notification and registration at this level in Lagos State and the first of its kind in Nigeria. It includes programmatic activities that promote simple, sustainable IT tools, such as creating an online death notification portal, and also raises public awareness and engages partners to improve mortality data. The online death notification portal is used by individuals and organizations working on CRVS to enter important data—such as deaths due to road traffic crashes and in health facilities—and send the data to authorities, who can then use the data to inform the government’s decision-making and policy development, including how to help prevent deaths in these areas.

Have you seen improvements in death notification and registration so far?

Orah: The latest data shows that 8,457 deaths were reported for 2022, which surpassed by 173% the baseline figure of 3,092 from 2021. This increase in death notifications significantly improved access to data necessary for public health policy formulation. It suggests that improvements to the death notification process have made it easier for health facilities to report deaths directly to the National Population Commission via the digital portal. We also established a formal CRVS network and institutional death notification system and trained medical students and doctors on how to certify deaths. Though there are opportunities for further improvement, the project has achieved recognition for our continued collaboration with other stakeholder agencies in Lagos State.

This project has certainly been a big undertaking for your team. What are some challenges you have encountered?

Orah: Earlier I mentioned that there was an increase in deaths reported, from 3,092 to 8,457. However, of those reports, only 2,370 eventually resulted in a death certificate. This is because, although health facilities can now report a death using the online data portal, the person’s family members still need to physically visit the National Population Commission office to obtain a death certificate. Many people still don’t understand the importance of registering and certifying deaths. There are other challenges for increasing registration and certification. For example, families have little or no incentive to comply with the regulations, and there are inadequate numbers of registration staff and death certifiers, so the process can be time consuming.. In addition, many deaths occur outside medical facilities, especially in rural areas.

How did you identify these challenges and how will you address them?

Keshinro: We identified these challenges by mapping the business process for death registration in collaboration with various stakeholders, including the National Population Commission, Nigeria Police Force, Ministry of Health, Nigerian Medical Association, religious leaders and other government parastatals. As a first step toward solving these problems, our project team from the Nigeria Police Force Pathologist Office held an inaugural awareness symposium with the National Population Commission in July 2022 with more than 500 participants who represented government agencies, doctors and other health workers, funeral directors, religious leaders, disaster response staff, the armed forces, and the media.

What’s next? 

Keshinro: We will continue to strengthen the CRVS network between institutional death notifiers and the National Population Commission. The death notification portal also continues to be a major part of the success of this project, and we are currently working on a proposal with the commission to have it fully adopted statewide. We are confident the efforts we’ve made to address challenges will result in smoother and more sustainable implementation of the recommendations and support for future priorities to improve CRVS in Lagos State and nationally in Nigeria.